Healthcare Provider Details

I. General information

NPI: 1235495979
Provider Name (Legal Business Name): LARK'S NEST FAMILY COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 MEDICO LN SUITE A
SANTA FE NM
87505-4786
US

IV. Provider business mailing address

422 MEDICO LN SUITE A
SANTA FE NM
87505-4786
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-1365
  • Fax: 505-254-1453
Mailing address:
  • Phone: 505-954-1365
  • Fax: 505-254-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0142451
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0145811
License Number StateNM

VIII. Authorized Official

Name: DR. MICHELE JOHNSON
Title or Position: CLINICAL DIRECTOR
Credential: EDD, BCPC, LMFT
Phone: 505-954-1365