Healthcare Provider Details

I. General information

NPI: 1699147553
Provider Name (Legal Business Name): MER OTIS JD MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 PASEO DEL CANON W
TAOS NM
87571-6943
US

IV. Provider business mailing address

105 PASEO DEL CANON W
TAOS NM
87571-6943
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5857
  • Fax:
Mailing address:
  • Phone: 575-758-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4155
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0177191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: