Provider Demographics
NPI:1174715767
Name:BERNAL, MINDY MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:MARIE
Last Name:BERNAL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2436 SUNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7763
Mailing Address - Country:US
Mailing Address - Phone:505-302-6872
Mailing Address - Fax:
Practice Address - Street 1:2436 SUNRIDGE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7763
Practice Address - Country:US
Practice Address - Phone:505-302-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLMSW101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47043Medicaid