Basic Information
| Provider Information | |||||||||
| NPI: | 1487960704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GOGGIN | ||||||||
| OtherFirstName: | CINDY | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 1349 | ||||||||
| Address2: | |||||||||
| City: | SILVER CITY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880621349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753884497 | ||||||||
| FaxNumber: | 5755341150 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 W HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | DEMING | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880304046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753884497 | ||||||||
| FaxNumber: | 5755341150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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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 | 106H00000X | 0152761 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 95057072 | 05 | NM | MEDICAID |