Provider Demographics
NPI:1457898348
Name:MENTAL HEALTH WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MENTAL HEALTH WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFRENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-532-1888
Mailing Address - Street 1:3855 FOOTHILLS RD STE C
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4772
Mailing Address - Country:US
Mailing Address - Phone:575-520-2861
Mailing Address - Fax:575-652-4937
Practice Address - Street 1:3855 FOOTHILLS RD STE C
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-520-2861
Practice Address - Fax:575-652-4937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53627580Medicaid