Provider Demographics
NPI:1699417030
Name:WAGNER, RUTH LARA
Entity type:Individual
Prefix:
First Name:RUTH LARA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EL MOLINO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2915
Mailing Address - Country:US
Mailing Address - Phone:575-323-8900
Mailing Address - Fax:
Practice Address - Street 1:350 EL MOLINO BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2915
Practice Address - Country:US
Practice Address - Phone:575-323-8900
Practice Address - Fax:575-323-8900
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NMCTB-2023-0321101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92751083Medicaid