Provider Demographics
NPI:1659608065
Name:MCDANIEL-JOHANSEN, CYNTHIA (LPC, PHD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MCDANIEL-JOHANSEN
Suffix:
Gender:F
Credentials:LPC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 BLACKTAIL DEER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5220
Mailing Address - Country:US
Mailing Address - Phone:575-526-9878
Mailing Address - Fax:575-526-7835
Practice Address - Street 1:121 WYATT DR STE 7
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2960
Practice Address - Country:US
Practice Address - Phone:575-526-9878
Practice Address - Fax:575-526-7835
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63257101YP2500X
103T00000X
NM0190391101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX63257OtherTEXAS LPC LICENSE