=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235495979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARK'S NEST FAMILY COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2012
-----------------------------------------------------
Last Update Date | 05/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 422 MEDICO LN SUITE A
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-954-1365
-----------------------------------------------------
Fax | 505-254-1453
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 422 MEDICO LN SUITE A
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-954-1365
-----------------------------------------------------
Fax | 505-254-1453
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. MICHELE JOHNSON
-----------------------------------------------------
Credential | EDD, BCPC, LMFT
-----------------------------------------------------
Telephone | 505-954-1365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0142451
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 0145811
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------