Provider Demographics
NPI:1952533267
Name:MONTOYA, MYCCA S (LMFT)
Entity type:Individual
Prefix:MS
First Name:MYCCA
Middle Name:S
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 WAGON MOUND, HWY 120
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:NM
Mailing Address - Zip Code:87743
Mailing Address - Country:US
Mailing Address - Phone:575-373-5117
Mailing Address - Fax:
Practice Address - Street 1:1335 GUSDORF ROAD
Practice Address - Street 2:BUILDING E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-445-9761
Practice Address - Fax:575-445-2887
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0189751106H00000X
NM0176281106H00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No174400000XOther Service ProvidersSpecialist