Healthcare Provider Details

I. General information

NPI: 1528764073
Provider Name (Legal Business Name): WILLOW RUTH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524B BISHOPS LODGE RD
SANTA FE NM
87506-0209
US

IV. Provider business mailing address

PO BOX 449
TESUQUE NM
87574-0449
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-6158
  • Fax:
Mailing address:
  • Phone: 505-983-6158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0964
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: