Healthcare Provider Details

I. General information

NPI: 1164637476
Provider Name (Legal Business Name): MARGO MARY CHURCHILL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CALLE PAISANO
SANTA FE NM
87505-5718
US

IV. Provider business mailing address

112 CALLE PAISANO
SANTA FE NM
87505-5718
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-1973
  • Fax: 505-983-2439
Mailing address:
  • Phone: 505-992-1973
  • Fax: 505-983-2439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0080551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: