Healthcare Provider Details

I. General information

NPI: 1063238327
Provider Name (Legal Business Name): GRETCHEN WACHS LPCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 SAINT FRANCIS DR
SANTA FE NM
87505-4332
US

IV. Provider business mailing address

PO BOX 611
TESUQUE NM
87574-0611
US

V. Phone/Fax

Practice location:
  • Phone: 505-501-0962
  • Fax:
Mailing address:
  • Phone: 505-501-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GRETCHEN WACHS
Title or Position: PSYCHOTHERAPIST
Credential: LPCC
Phone: 505-501-0962