Provider Demographics
NPI:1417027137
Name:VANWYNGARDEN, HARRIET LUCKETT (LPCC, LMSW)
Entity type:Individual
Prefix:MS
First Name:HARRIET
Middle Name:LUCKETT
Last Name:VANWYNGARDEN
Suffix:
Gender:F
Credentials:LPCC, LMSW
Other - Prefix:MS
Other - First Name:HARRIET
Other - Middle Name:LUCKETT
Other - Last Name:VAN WYNGARDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPCC, LMSW
Mailing Address - Street 1:146 BLACKTAIL DEER AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-5220
Mailing Address - Country:US
Mailing Address - Phone:575-649-7753
Mailing Address - Fax:575-526-7835
Practice Address - Street 1:121 WYATT DR STE 7
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2960
Practice Address - Country:US
Practice Address - Phone:575-649-7753
Practice Address - Fax:575-526-7835
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-16571041C0700X
NM0337101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB9416Medicaid