Healthcare Provider Details

I. General information

NPI: 1760923247
Provider Name (Legal Business Name): WILLYMAE SMITH-MCNEAL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date: 01/07/2019
Reactivation Date: 01/22/2019

III. Provider practice location address

107 SUNSET LOOP
MESCALERO NM
88340-0228
US

IV. Provider business mailing address

16 CARRIZO TRL
MESCALERO NM
88340-9766
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4433
  • Fax: 575-464-4331
Mailing address:
  • Phone: 575-464-4433
  • Fax: 575-464-4331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT0184841
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: