Provider Demographics
NPI:1518131689
Name:LIGHTMOON, DIANA (MA, LPCC, LMT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:
Last Name:LIGHTMOON
Suffix:
Gender:F
Credentials:MA, LPCC, LMT
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:ORMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, MA
Mailing Address - Street 1:29 CHAPALA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-2206
Mailing Address - Country:US
Mailing Address - Phone:505-577-4607
Mailing Address - Fax:505-466-1277
Practice Address - Street 1:5 CALIENTE RD STE 2C
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-9205
Practice Address - Country:US
Practice Address - Phone:505-577-4607
Practice Address - Fax:505-466-1277
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0228101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM67985041Medicaid