Healthcare Provider Details

I. General information

NPI: 1235732660
Provider Name (Legal Business Name): MIMBRES COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 CALLE BLANCA
CORRALES NM
87048-7825
US

IV. Provider business mailing address

23 CALLE BLANCA
CORRALES NM
87048-7825
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-0592
  • Fax:
Mailing address:
  • Phone: 575-621-0592
  • 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: EFSTATHIA YERENDE
Title or Position: OWNER
Credential: LPCC
Phone: 575-621-0592