Healthcare Provider Details

I. General information

NPI: 1447722988
Provider Name (Legal Business Name): WILLIAM K BLYTHE LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 BARBARA LOOP SE
RIO RANCHO NM
87124-1039
US

IV. Provider business mailing address

1645 UNIVERSITY BLVD NE
ALBUQUERQUE NM
87102-1710
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-9911
  • Fax:
Mailing address:
  • Phone: 505-842-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2023-0586
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB-2023-0586
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: