=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992333579
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE MARIE BRYAN LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2020
-----------------------------------------------------
Last Update Date | 07/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 MARSHALL ST
-----------------------------------------------------
City | T OR C
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87901-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-297-0171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 MARSHALL ST
-----------------------------------------------------
City | TRUTH OR CONSEQUENCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87901-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-740-5096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number | 846
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | CTB-2024-0308
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------