Basic Information
Provider Information | |||||||||
NPI: | 1063997161 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMANECER COMMUNITY COUNSELING CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2671 | ||||||||
Address2: |   | ||||||||
City: | ANTHONY | ||||||||
State: | NM | ||||||||
PostalCode: | 880212671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5758825100 | ||||||||
FaxNumber: | 5758821151 | ||||||||
Practice Location | |||||||||
Address1: | 128 WYATT DR | ||||||||
Address2: |   | ||||||||
City: | LAS CRUCES | ||||||||
State: | NM | ||||||||
PostalCode: | 880052925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5758825100 | ||||||||
FaxNumber: | 5758821151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/25/2018 | ||||||||
LastUpdateDate: | 09/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | CLAUDIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5758825100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 35650338 | 05 | NM |   | MEDICAID |