Healthcare Provider Details

I. General information

NPI: 1881887016
Provider Name (Legal Business Name): TARA KATHRYN THELEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2007
Last Update Date: 08/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8338 COMANCHE RD NE STE B
ALBUQUERQUE NM
87110-2357
US

IV. Provider business mailing address

8338 COMANCHE RD NE STE B
ALBUQUERQUE NM
87110-2357
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-3665
  • Fax: 505-323-1038
Mailing address:
  • Phone: 505-323-3665
  • Fax: 505-323-1038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0100161
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: