Provider Demographics
NPI:1124456298
Name:LAITY, ELAINE (LPC, MA)
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:LAITY
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 MONTREAL LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-8452
Mailing Address - Country:US
Mailing Address - Phone:505-867-3470
Mailing Address - Fax:
Practice Address - Street 1:4212 MONTREAL LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-8452
Practice Address - Country:US
Practice Address - Phone:505-867-3470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0311101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health