Healthcare Provider Details

I. General information

NPI: 1790714822
Provider Name (Legal Business Name): TRACY ANN REAGAN KIELE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SUDDERTH
RUIDOSO NM
88345
US

IV. Provider business mailing address

1320 S. SOLANO
LAS CRUCES NM
88001
US

V. Phone/Fax

Practice location:
  • Phone: 575-630-0571
  • Fax: 575-630-0574
Mailing address:
  • Phone: 575-527-7900
  • Fax: 575-571-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number422
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0147561
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: