Healthcare Provider Details

I. General information

NPI: 1285480632
Provider Name (Legal Business Name): MS. KAREN WILLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 W HISTORIC HIGHWAY 66
GALLUP NM
87301-6812
US

IV. Provider business mailing address

PO BOX 3741
GALLUP NM
87305-3741
US

V. Phone/Fax

Practice location:
  • Phone: 505-297-3967
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: