Healthcare Provider Details

I. General information

NPI: 1780069013
Provider Name (Legal Business Name): SUSAN KING LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SAINT MICHAELS DR STE 2
SANTA FE NM
87505-7655
US

IV. Provider business mailing address

1566 SIPAPU LN
SANTA FE NM
87507-4012
US

V. Phone/Fax

Practice location:
  • Phone: 505-057-7721
  • Fax:
Mailing address:
  • Phone: 505-660-2888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMN0200241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: