Healthcare Provider Details

I. General information

NPI: 1548565187
Provider Name (Legal Business Name): TERI J RICHARDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E FAIRVIEW LN
ESPANOLA NM
87532-2822
US

IV. Provider business mailing address

2041 S PACHECO ST STE 100
SANTA FE NM
87505-6478
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-1991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0111721
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: