Provider Demographics
NPI:1760192413
Name:PERALTA, KRISTIN (LSAA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 S ATKINSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-7154
Mailing Address - Country:US
Mailing Address - Phone:575-578-4826
Mailing Address - Fax:575-578-4828
Practice Address - Street 1:1107 S ATKINSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-7154
Practice Address - Country:US
Practice Address - Phone:575-578-4826
Practice Address - Fax:575-578-4828
Is Sole Proprietor?:No
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0296101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15743304Medicaid