Healthcare Provider Details

I. General information

NPI: 1518791003
Provider Name (Legal Business Name): RYAN MULNICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DRIVER STE 102
SANTA FE NM
87507-4903
US

IV. Provider business mailing address

PO BOX 330
TAOS NM
87571-0330
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9437
  • Fax: 505-930-5427
Mailing address:
  • Phone: 208-315-3663
  • 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:
Title or Position:
Credential:
Phone: