Healthcare Provider Details

I. General information

NPI: 1417240425
Provider Name (Legal Business Name): ROXANNE GEORGE PH.D., LMFT, EMDR-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 03/04/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195A STATE RD 240
RANCHOS DE TAOS NM
87557-7811
US

IV. Provider business mailing address

4 SAN FRANCISCO RD UNIT 1769
RANCHOS DE TAOS NM
87557-4071
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4270
  • Fax: 505-633-7620
Mailing address:
  • Phone: 575-758-4270
  • Fax: 505-633-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0185271
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: