Provider Demographics
NPI:1083135552
Name:LUNA Y SOL LIFE SERVICES
Entity Type:Organization
Organization Name:LUNA Y SOL LIFE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PLCSW
Authorized Official - Phone:575-626-6349
Mailing Address - Street 1:PO BOX 2773
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-2773
Mailing Address - Country:US
Mailing Address - Phone:575-626-6349
Mailing Address - Fax:
Practice Address - Street 1:2001 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-1752
Practice Address - Country:US
Practice Address - Phone:575-626-6349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1245620400Medicaid