Healthcare Provider Details

I. General information

NPI: 1700601697
Provider Name (Legal Business Name): BLYTHE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6708 VISTA LUCES ST NW
ALBUQUERQUE NM
87120-7067
US

IV. Provider business mailing address

6708 VISTA LUCES ST NW
ALBUQUERQUE NM
87120-7067
US

V. Phone/Fax

Practice location:
  • Phone: 505-264-9289
  • Fax:
Mailing address:
  • Phone: 505-264-9289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM K BLYTHE
Title or Position: AGENT/SOLE MEMBER
Credential: LPCC
Phone: 505-264-9289