Healthcare Provider Details

I. General information

NPI: 1255861209
Provider Name (Legal Business Name): MIKAHLA KRISTEN BEUTLER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE B
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

PO BOX 727
TESUQUE NM
87574-0727
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-7311
  • Fax:
Mailing address:
  • Phone: 505-699-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0173411
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: