MEDICARE: METAMORPHOSIS COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	101YS0200X	School Counselor
4	101Y00000X	Counselor

General Provider Information

NPI Number	:	1861167900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METAMORPHOSIS COUNSELING LLC

Provider Business Mailing Address
First Line	:	1003 DON JUAN ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-2411
Country	:	US
Telephone Number	:	530-953-8876
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 MARQUEZ PL STE D5
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-1724
Country	:	US
Telephone Number	:	530-953-8876
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. MELODY VAN HOOSE
Credential	:	LPCC
Telephone Number	:	530-953-8876

Provider Enumeration Date	:	08/11/2021
Last Update Date	:	08/11/2021

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