=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770901506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2014
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 LUISA ST
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-310-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1421 LUISA ST STE O
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-310-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | LORRI J BALLARD
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-310-1876
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0188661
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------