Provider Demographics
NPI:1912316308
Name:A PLACE OF HEALING LLC
Entity Type:Organization
Organization Name:A PLACE OF HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:TREVINO
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LPCC
Authorized Official - Phone:5754-644-9209
Mailing Address - Street 1:5065 COMANCHE TRL
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7376
Mailing Address - Country:US
Mailing Address - Phone:575-644-9209
Mailing Address - Fax:575-647-5050
Practice Address - Street 1:121 WYATT DR STE 5
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2960
Practice Address - Country:US
Practice Address - Phone:575-644-9209
Practice Address - Fax:575-647-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0116921101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04932862Medicaid
NM1477626299OtherINDIVIDUAL NPI#