Healthcare Provider Details

I. General information

NPI: 1437866100
Provider Name (Legal Business Name): CAROLYN SHAYTE CTB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 CAMINO BAJO
SANTA FE NM
87508-8614
US

IV. Provider business mailing address

256 PLAZA CANADA # A
SANTA FE NM
87501-2373
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-7684
  • Fax:
Mailing address:
  • Phone: 443-955-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0862
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: