Basic Information
| Provider Information | |||||||||
| NPI: | 1669792008 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHUA | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875928220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054715006 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 PASEO DEL PUEBLO SUR | ||||||||
| Address2: | |||||||||
| City: | TAOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875715922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757587263 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 106H00000X | 0146101 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.