=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750247367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KOREY SHRADER LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2025
-----------------------------------------------------
Last Update Date | 12/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 COWBOY WAY
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015-9616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-750-2707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 SERRANIA DR
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015-9071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-750-2707
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | CTB-2025-0942
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------