=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730617333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUN MOUNTAIN COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2017
-----------------------------------------------------
Last Update Date | 05/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1911 5TH ST STE 210
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-438-1853
-----------------------------------------------------
Fax | 505-438-2475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2635
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87504-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-438-1853
-----------------------------------------------------
Fax | 505-438-2475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MARTIN KLEHN
-----------------------------------------------------
Credential | LCSW/LADAC
-----------------------------------------------------
Telephone | 505-438-1853
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C-04823
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------