Healthcare Provider Details

I. General information

NPI: 1871016568
Provider Name (Legal Business Name): MIKAHLA BEUTLER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE C
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: 505-663-6464
  • Fax:
Mailing address:
  • Phone: 505-699-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number173411
License Number StateNM

VIII. Authorized Official

Name: MS. MIKAHLA KRISTIN BEUTLER
Title or Position: PSYCHOTHERAPIST
Credential: MA, LPCC
Phone: 505-699-7311