Healthcare Provider Details

I. General information

NPI: 1912832205
Provider Name (Legal Business Name): CALICO THERAPY AND SUPERVISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7825
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7825
US

V. Phone/Fax

Practice location:
  • Phone: 505-917-4083
  • Fax:
Mailing address:
  • Phone: 505-554-0373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: REYNETTE I BEYNON
Title or Position: FOUNDER/MENTAL HEALTH THERAPIST
Credential: LPCC, LPC
Phone: 505-917-4083