Healthcare Provider Details

I. General information

NPI: 1639992811
Provider Name (Legal Business Name): ELIZABETH SLOAN-OBRIEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LUISA ST STE 7
SANTA FE NM
87505-4177
US

IV. Provider business mailing address

1300 LUISA ST STE 7
SANTA FE NM
87505-4177
US

V. Phone/Fax

Practice location:
  • Phone: 505-416-8009
  • Fax:
Mailing address:
  • Phone: 845-863-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2024-0770
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: