Basic Information
| Provider Information | |||||||||
| NPI: | 1265601652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHERYL | ||||||||
| FirstName: | KRISTENE | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 S. SOLANO | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755277900 | ||||||||
| FaxNumber: | 5755714872 | ||||||||
| Practice Location | |||||||||
| Address1: | 332 E. MOTEL DRIVE | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755423304 | ||||||||
| FaxNumber: | 5755423305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2008 | ||||||||
| LastUpdateDate: | 03/29/2014 | ||||||||
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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 | 101YA0400X | 0110461 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 89129229 | 05 | NM | MEDICAID | 18677037 | 05 | NM | MEDICAID |