Provider Demographics
NPI:1386779262
Name:MEDEIROS, SARAH JOY (LPCC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JOY
Last Name:MEDEIROS
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4430
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-4430
Mailing Address - Country:US
Mailing Address - Phone:575-882-5101
Mailing Address - Fax:575-882-6127
Practice Address - Street 1:820 HWY 478
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021
Practice Address - Country:US
Practice Address - Phone:575-882-5101
Practice Address - Fax:575-882-6127
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM0116231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24271888Medicaid