Healthcare Provider Details

I. General information

NPI: 1972032563
Provider Name (Legal Business Name): ALYSSA BUTLER LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 11/02/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1409 ZEPOL RD APT 110
SANTA FE NM
87507
US

IV. Provider business mailing address

707 BROADWAY BLVD NE
ALBUQUERQUE NM
87102-2360
US

V. Phone/Fax

Practice location:
  • Phone: 847-420-1897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCCMH0217651
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0196401
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0217651
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CL0196401
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: