Basic Information
| Provider Information | |||||||||
| NPI: | 1689972036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTOS RODRIGUEZ | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6621 DONIPHAN DR STE G | ||||||||
| Address2: | |||||||||
| City: | CANUTILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 798355005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9158775100 | ||||||||
| FaxNumber: | 9158775107 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 MCNUTT RD | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880089606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9154221968 | ||||||||
| FaxNumber: | 9158775107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 04/28/2017 | ||||||||
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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 | 101YP2500X | 0171681 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 64153274 | 05 | NM | MEDICAID | 70336849 | 05 | NM | MEDICAID |