Healthcare Provider Details

I. General information

NPI: 1679389415
Provider Name (Legal Business Name): TERESA MITCHELL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

IV. Provider business mailing address

2111 COLLEGE DR
GALLUP NM
87301-5600
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-5172
  • Fax:
Mailing address:
  • Phone: 505-397-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0836
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: