Provider Demographics
NPI:1073682357
Name:MY HEALING SPACE
Entity Type:Organization
Organization Name:MY HEALING SPACE
Other - Org Name:MY HEALING SPACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THERAPIST OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ATENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC LADAC
Authorized Official - Phone:505-644-0399
Mailing Address - Street 1:4500 GERALD DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007
Mailing Address - Country:US
Mailing Address - Phone:505-644-6457
Mailing Address - Fax:505-647-8922
Practice Address - Street 1:302 W GRIGGS
Practice Address - Street 2:#9
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:505-644-6457
Practice Address - Fax:505-647-8922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI4400101Y00000X
NM0070621101Y00000X
NM0099031101Y00000X
NM4313101Y00000X
NM0100821101Y00000X
NM03 067732 00 7251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty