=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295281566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTOPHER H WEATHERS LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2016
-----------------------------------------------------
Last Update Date | 09/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 GUSDORF RD STE A
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-6914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-770-7139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 JMA RANCH RD
-----------------------------------------------------
City | EL PRADO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87529-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-770-7139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | X-09715
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | X-09715
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------