Healthcare Provider Details

I. General information

NPI: 1376814137
Provider Name (Legal Business Name): RIVERBEAR COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16306 HWY 64/84
CHAMA NM
87520
US

IV. Provider business mailing address

P.O. BOX 1241
CHAMA NM
87520-1241
US

V. Phone/Fax

Practice location:
  • Phone: 575-209-1769
  • Fax: 575-756-1560
Mailing address:
  • Phone: 575-756-1560
  • Fax: 575-756-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0091811
License Number StateNM

VIII. Authorized Official

Name: STEPHANIE HORNER
Title or Position: OWNER
Credential: LPCC
Phone: 575-756-1560