Basic Information
| Provider Information | |||||||||
| NPI: | 1619441227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRALL | ||||||||
| FirstName: | CATHARYN | ||||||||
| MiddleName: | DIANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LMHC, NCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRALL | ||||||||
| OtherFirstName: | CATHARYN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7301 INDIAN SCHOOL RD NE STE A | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871104504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052660441 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1907 CENTRAL AVE STE 214 | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875444017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053090505 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2019 | ||||||||
| LastUpdateDate: | 02/28/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | CMH0204871 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 38406861 | 05 | NM | MEDICAID |