Provider Demographics
NPI:1295698280
Name:MOYA, SELENA EBONY (LSAA)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:EBONY
Last Name:MOYA
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 N RAILROAD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3159
Mailing Address - Country:US
Mailing Address - Phone:505-747-8187
Mailing Address - Fax:
Practice Address - Street 1:1227 N RAILROAD AVE STE C
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3159
Practice Address - Country:US
Practice Address - Phone:505-747-8187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-12-05
Last Update Date:2025-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0970101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)