Provider Demographics
NPI:1811383367
Name:ACOSTA, MIRTHA DIBELY (LMHC)
Entity Type:Individual
Prefix:
First Name:MIRTHA
Middle Name:DIBELY
Last Name:ACOSTA
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:PO BOX 7065
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87194-7065
Mailing Address - Country:US
Mailing Address - Phone:505-243-2223
Mailing Address - Fax:505-243-3576
Practice Address - Street 1:803 TIJERAS AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3096
Practice Address - Country:US
Practice Address - Phone:505-243-2223
Practice Address - Fax:505-243-3576
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-11
Last Update Date:2015-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0173241101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87177056Medicaid