Healthcare Provider Details

I. General information

NPI: 1902287626
Provider Name (Legal Business Name): RICHARD MIETZ LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2503 RIDGE RUNNER RD
LAS VEGAS NM
87701-4972
US

IV. Provider business mailing address

2551 COORS BLVD NW
ALBUQUERQUE NM
87120-1213
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-8265
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0167621
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: