Healthcare Provider Details

I. General information

NPI: 1023494937
Provider Name (Legal Business Name): TARA LYNN RICHARDSON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 05/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2469 CORRALES RD SUITE E
CORRALES NM
87048-9146
US

IV. Provider business mailing address

6200 EUBANK BLVD NE 1722
ALBUQUERQUE NM
87111-7379
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-1871
  • Fax:
Mailing address:
  • Phone: 989-854-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0174641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: