=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679240998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES EDWARD NEELLEY JR. LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2021
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 BERTHA RD STE B
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-7148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-758-4297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1598
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-1598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-779-2294
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | CMH0151031
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------