=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679179840
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PECOS VALLEY COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 614 BECKER AVE
-----------------------------------------------------
City | BELEN
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87002-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-517-0931
-----------------------------------------------------
Fax | 575-706-9426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1894 CHAPARRAL LOOP
-----------------------------------------------------
City | SOCORRO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87801-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-517-0931
-----------------------------------------------------
Fax | 575-706-9426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. DAVID L WRIGHT
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 575-517-0931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------