Healthcare Provider Details

I. General information

NPI: 1760544233
Provider Name (Legal Business Name): JUDITH ANN WEISSMUELLER B.A., L.P.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1487 CLARK RD
SANTA FE NM
87507-5174
US

IV. Provider business mailing address

1487 CLARK RD
SANTA FE NM
87507-5174
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-5268
  • Fax:
Mailing address:
  • Phone: 505-474-5268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1805
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: