Provider Demographics
NPI:1427352350
Name:VENERABLE, THALIA (LMT)
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:
Last Name:VENERABLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704B LLANO ST # 144
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5460
Mailing Address - Country:US
Mailing Address - Phone:505-795-1804
Mailing Address - Fax:
Practice Address - Street 1:2074 GALISTEO ST STE A4
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2104
Practice Address - Country:US
Practice Address - Phone:505-795-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMO225174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist