Provider Demographics
NPI:1871646950
Name:MORA, GENETTE RACHEL (LMFT)
Entity Type:Individual
Prefix:
First Name:GENETTE
Middle Name:RACHEL
Last Name:MORA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 DON FERNANDO ST
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-5953
Mailing Address - Country:US
Mailing Address - Phone:575-751-7037
Mailing Address - Fax:
Practice Address - Street 1:314 DON FERNANDO ST
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5953
Practice Address - Country:US
Practice Address - Phone:575-751-7037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 49836106H00000X
NM0164941106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM597-557-884Medicaid