Provider Demographics
NPI:1477626299
Name:MOLINA, AMY LYN (EDS, LPCC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYN
Last Name:MOLINA
Suffix:
Gender:
Credentials:EDS, LPCC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:LYN
Other - Last Name:TREVINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDS, LPCC
Mailing Address - Street 1:PO BOX 1993
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1993
Mailing Address - Country:US
Mailing Address - Phone:575-644-9209
Mailing Address - Fax:
Practice Address - Street 1:1625 SPRUCE AVE SPC 98
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-2471
Practice Address - Country:US
Practice Address - Phone:575-644-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0116921101YP2500X
NMCCMH0116921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68889020Medicaid