Healthcare Provider Details

I. General information

NPI: 1619584182
Provider Name (Legal Business Name): MARYBETH HALLMAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 LUISA ST STE 10
SANTA FE NM
87505-4176
US

IV. Provider business mailing address

1219 LUISA ST STE 10
SANTA FE NM
87505-4176
US

V. Phone/Fax

Practice location:
  • Phone: 505-458-8188
  • Fax:
Mailing address:
  • Phone: 505-458-8188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0210571
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: