Provider Demographics
NPI:1003171364
Name:TERRY MAYNES LICENSED PROFESSIONAL CLINICAL COUNSELOR
Entity Type:Organization
Organization Name:TERRY MAYNES LICENSED PROFESSIONAL CLINICAL COUNSELOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:575-313-3698
Mailing Address - Street 1:120 ARENAS VALLEY
Mailing Address - Street 2:TERRY MAYNES
Mailing Address - City:ARENAS VALLEY
Mailing Address - State:NM
Mailing Address - Zip Code:88022
Mailing Address - Country:US
Mailing Address - Phone:575-313-3698
Mailing Address - Fax:
Practice Address - Street 1:120 ARENAS VALLEY RD
Practice Address - Street 2:TERRY MAYNES
Practice Address - City:ARENAS VALLEY
Practice Address - State:NM
Practice Address - Zip Code:88022
Practice Address - Country:US
Practice Address - Phone:575-313-3698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0144471251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health