Healthcare Provider Details

I. General information

NPI: 1649044710
Provider Name (Legal Business Name): MAVIS SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RT 9 HWY 371 SUITE 2
CROWNPOINT NM
87313
US

IV. Provider business mailing address

P.O. BOX 1501
GALLUP NM
87305
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-2333
  • Fax:
Mailing address:
  • Phone: 505-870-1347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH02077711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: