Provider Demographics
NPI:1558032318
Name:ONTIVEROS, GERIANNE DALYNN (LMHC)
Entity Type:Individual
Prefix:
First Name:GERIANNE
Middle Name:DALYNN
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-7335
Mailing Address - Country:US
Mailing Address - Phone:575-777-2311
Mailing Address - Fax:
Practice Address - Street 1:101 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6306
Practice Address - Country:US
Practice Address - Phone:575-777-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0219161101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health