Basic Information
| Provider Information | |||||||||
| NPI: | 1619205507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILMETH | ||||||||
| FirstName: | LU ANN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, LPCC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16199 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880046199 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3012 LOOKOUT RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880111640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755415367 | ||||||||
| FaxNumber: | 5755321928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2009 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 005537 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 000D3972 | 05 | NM | MEDICAID |