Healthcare Provider Details

I. General information

NPI: 1538891569
Provider Name (Legal Business Name): KATE WORMAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 SIPAPU ST
TAOS NM
87571-6498
US

IV. Provider business mailing address

306 GUYORA LN
TAOS NM
87571-6550
US

V. Phone/Fax

Practice location:
  • Phone: 575-770-8614
  • Fax:
Mailing address:
  • Phone: 575-770-8614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATE WORMAN
Title or Position: OWNER
Credential: LPCC
Phone: 575-770-8614