Provider Demographics
NPI:1982324588
Name:VITA, LAUREN ASHLEY (MA, NCSP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:VITA
Suffix:
Gender:F
Credentials:MA, NCSP
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 19000
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-9000
Mailing Address - Country:US
Mailing Address - Phone:575-769-4490
Mailing Address - Fax:575-769-4430
Practice Address - Street 1:1600 SUTTER PL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4611
Practice Address - Country:US
Practice Address - Phone:575-769-4490
Practice Address - Fax:575-769-4430
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM411693103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool