Healthcare Provider Details

I. General information

NPI: 1962773754
Provider Name (Legal Business Name): MARY EMALIE TIPTON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 S PACHECO ST
SANTA FE NM
87505-3997
US

IV. Provider business mailing address

17 AMORAK RD
RANCHOS DE TAOS NM
87557-8720
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8112
  • Fax:
Mailing address:
  • Phone: 575-224-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2023-0901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: