Provider Demographics
NPI:1952611980
Name:TRUJILLO, MYRNA J (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:J
Last Name:TRUJILLO
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2919 HILLRISE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4701
Mailing Address - Country:US
Mailing Address - Phone:575-522-9500
Mailing Address - Fax:575-523-1108
Practice Address - Street 1:2919 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4701
Practice Address - Country:US
Practice Address - Phone:575-522-9500
Practice Address - Fax:575-523-1108
Is Sole Proprietor?:No
Enumeration Date:2010-10-08
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29373395Medicaid