Provider Demographics
NPI:1336761287
Name:TRUJILLO, MEGHAN I (LSAA)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:TRUJILLO
Suffix:I
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:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:ALCALDE
Mailing Address - State:NM
Mailing Address - Zip Code:87511-0178
Mailing Address - Country:US
Mailing Address - Phone:505-423-3353
Mailing Address - Fax:
Practice Address - Street 1:1227 N RAILROAD AVE STE C
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3159
Practice Address - Country:US
Practice Address - Phone:505-423-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0210881101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)