Healthcare Provider Details

I. General information

NPI: 1184124133
Provider Name (Legal Business Name): ALTA MITCHELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W MALONEY AVE
GALLUP NM
87301-5214
US

IV. Provider business mailing address

PO BOX 251
FORT WINGATE NM
87316-0251
US

V. Phone/Fax

Practice location:
  • Phone: 505-879-5656
  • Fax:
Mailing address:
  • Phone: 505-879-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0071741
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: