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General NPI Number Information
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NPI Number | 1548744071
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Entity Type | Individual
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Provider Name | STACEY MCMULLEN MSW
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Gender | Female
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Dates
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Enumeration Date | 09/20/2018
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Last Update Date | 09/20/2018
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Provider Practice Location Address
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Address Line | 1501 CERRILLOS RD
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City | SANTA FE
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State | NM
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Zip | 87505-3521
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Country | US
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Telephone | 505-216-7325
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Fax | 505-395-7406
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Provider Business Mailing Address
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Address Line | PO BOX 23625
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City | SANTA FE
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State | NM
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Zip | 87502-3625
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Country | US
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Telephone | 505-660-8559
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | X-10748
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License Number State | NM
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