Provider Demographics
NPI:1912461252
Name:BEJARANO, LAURA ANGEL (RMTI, LMMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANGEL
Last Name:BEJARANO
Suffix:
Gender:F
Credentials:RMTI, LMMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8042
Mailing Address - Country:US
Mailing Address - Phone:575-312-4555
Mailing Address - Fax:
Practice Address - Street 1:701 WINDMILL DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8042
Practice Address - Country:US
Practice Address - Phone:575-312-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8626111NR0400X, 172M00000X, 173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No172M00000XOther Service ProvidersMechanotherapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM03-377874-00-4OtherCRS