Healthcare Provider Details

I. General information

NPI: 1144767369
Provider Name (Legal Business Name): DYLAN OTTEMILLER DRUSEDUM LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE STE 103
ALBUQUERQUE NM
87102-2300
US

IV. Provider business mailing address

104 SERENITY HILLS PL SE
ALBUQUERQUE NM
87123-3970
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-4639
  • Fax:
Mailing address:
  • Phone: 717-495-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0194881
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: