Healthcare Provider Details

I. General information

NPI: 1487989679
Provider Name (Legal Business Name): NATALIE CLAYSHULTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2009
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MENAUL BLVD NE CENTER FOR DEVELOPMENT AND DISABILITY
ALBUQUERQUE NM
87107-1851
US

IV. Provider business mailing address

933 BRADBURY DR SE
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3120
  • Fax: 505-272-8060
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0120291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: