Healthcare Provider Details

I. General information

NPI: 1750715645
Provider Name (Legal Business Name): KIDS COUNSELING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 STATE HIGHWAY 434
MORA NM
87732-0291
US

IV. Provider business mailing address

PO BOX 84
MORA NM
87732-0084
US

V. Phone/Fax

Practice location:
  • Phone: 575-642-8046
  • Fax:
Mailing address:
  • Phone: 575-642-8046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05483
License Number StateNM

VIII. Authorized Official

Name: BREENA TAFOYA
Title or Position: CEO / OWNER
Credential:
Phone: 575-642-8046