Healthcare Provider Details

I. General information

NPI: 1619113420
Provider Name (Legal Business Name): BETHANY D'AUN WILLIS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 505-896-0928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0795
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF60309365
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0218751
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: