Healthcare Provider Details

I. General information

NPI: 1700662368
Provider Name (Legal Business Name): MOLLIE FANNIN-FLETCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 OLD PECOS TRL STE A
SANTA FE NM
87505-4778
US

IV. Provider business mailing address

1614 CITY LIGHTS ST
SANTA FE NM
87507-0186
US

V. Phone/Fax

Practice location:
  • Phone: 505-657-9708
  • Fax: 505-395-9295
Mailing address:
  • Phone: 432-556-8897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0675
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: