Basic Information
| Provider Information | |||||||||
| NPI: | 1871900613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUJAN | ||||||||
| FirstName: | NITA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 S 4TH ST | ||||||||
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| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754720745 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
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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 | 101YM0800X | T-0167331 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.