Healthcare Provider Details

I. General information

NPI: 1750796058
Provider Name (Legal Business Name): GRETA CARSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SCHOOL ROAD
PENASCO NM
87553
US

IV. Provider business mailing address

PO BOX 1473
RANCHOS DE TAOS NM
87557-1473
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-1596
  • Fax:
Mailing address:
  • Phone: 505-316-6052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number136721
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number304196
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: