Provider Demographics
NPI:1689972036
Name:SANTOS RODRIGUEZ, SANDRA MICHELLE (LPCC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:SANTOS RODRIGUEZ
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6621 DONIPHAN DR STE G
Mailing Address - Street 2:
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-5005
Mailing Address - Country:US
Mailing Address - Phone:915-877-5100
Mailing Address - Fax:915-877-5107
Practice Address - Street 1:5300 MCNUTT RD
Practice Address - Street 2:SUITE 11
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9606
Practice Address - Country:US
Practice Address - Phone:915-422-1968
Practice Address - Fax:915-877-5107
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0171681101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64153274Medicaid
NM70336849Medicaid