Healthcare Provider Details

I. General information

NPI: 1245958958
Provider Name (Legal Business Name): MICHELLE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
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 2940
TAOS NM
87571-2940
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSWB-2024-0209
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: