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General NPI Number Information
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NPI Number | 1942637517
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Entity Type | Organization
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Legal Business Name | T WIARD LLC
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Dates
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Enumeration Date | 09/27/2013
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Last Update Date | 06/06/2024
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Provider Practice Location Address
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Address Line | 125 LA POSTA RD STE B15
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City | TAOS
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State | NM
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Zip | 87571-7242
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Country | US
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Telephone | 505-690-0126
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Fax |
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Provider Business Mailing Address
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Address Line | POST OFFICE BOX 569
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City | ARROYO HONDO
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State | NM
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Zip | 87513
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Country | US
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Telephone | 505-690-0126
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. THEODORE JOHN WIARD
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Credential | LPCC
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Telephone | 505-690-0126
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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 | 0109811
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License Number State | NM
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