Healthcare Provider Details

I. General information

NPI: 1306565569
Provider Name (Legal Business Name): HIDDEN VALLEY COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 08/23/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WAPITI LOOP VALLE ESCONDIDO
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 3139
TAOS NM
87571-3139
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-1484
  • Fax:
Mailing address:
  • Phone: 575-779-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LARISSA MARI WEINMAN
Title or Position: THERAPIST/COUNSELOR
Credential: LPCC
Phone: 575-779-1484