Healthcare Provider Details

I. General information

NPI: 1104129766
Provider Name (Legal Business Name): LAUREN KIMBALL TYLER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2010
Last Update Date: 05/25/2025
Certification Date: 05/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 GLITTER GULCH WAY
EDGEWOOD NM
87015-8738
US

IV. Provider business mailing address

7 GLITTER GULCH WAY
EDGEWOOD NM
87015-8738
US

V. Phone/Fax

Practice location:
  • Phone: 970-739-4626
  • Fax:
Mailing address:
  • Phone: 970-739-4626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0156401
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: