Healthcare Provider Details

I. General information

NPI: 1205643079
Provider Name (Legal Business Name): KELLIE L HALLAM BMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLIE L BIEHUNKO

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE P
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

229 DELFINA ST
SANTA FE NM
87505-4403
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-6483
  • Fax:
Mailing address:
  • Phone: 832-724-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2026-0762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: