Provider Demographics
NPI:1740513696
Name:TOLEDO- ONTIVEROS, MELISSA ANN (MA, MCJ, MPA)
Entity type:Individual
Prefix:MS
First Name:MELISSA ANN
Middle Name:
Last Name:TOLEDO- ONTIVEROS
Suffix:
Gender:F
Credentials:MA, MCJ, MPA
Other - Prefix:
Other - First Name:MELISSA ANN
Other - Middle Name:
Other - Last Name:PORTILLOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1430 E MESA AVE APT 18
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5786
Mailing Address - Country:US
Mailing Address - Phone:505-977-9722
Mailing Address - Fax:
Practice Address - Street 1:301 PERKINS DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3758
Practice Address - Country:US
Practice Address - Phone:505-977-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0129951101Y00000X
171M00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9311Medicaid