Healthcare Provider Details

I. General information

NPI: 1639291230
Provider Name (Legal Business Name): KELI MAUREEN DERSCH-BALDONADO LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12124 STATE HIGHWAY 14 N
CEDAR CREST NM
87008-9313
US

IV. Provider business mailing address

12124 STATE HIGHWAY 14 N
CEDAR CREST NM
87008-9313
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-8119
  • Fax: 505-281-3557
Mailing address:
  • Phone: 505-250-8119
  • Fax: 505-281-3557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0099941
License Number StateNM

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: