Healthcare Provider Details

I. General information

NPI: 1518791003
Provider Name (Legal Business Name): RYAN MULNICK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BERTHA RD STE B
TAOS NM
87571-7148
US

IV. Provider business mailing address

PO BOX 330
TAOS NM
87571-0330
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-4297
  • Fax:
Mailing address:
  • Phone: 208-315-3663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: