Provider Demographics
NPI:1629270707
Name:TELLES, DIANA M (LMFT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:M
Last Name:TELLES
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:MARIE
Other - Last Name:TELLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:385 CALLE DE ALEGRA STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:100 W GRIGGS AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1234
Practice Address - Country:US
Practice Address - Phone:575-647-2800
Practice Address - Fax:575-647-2898
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0108851106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid