Basic Information
| Provider Information | |||||||||
| NPI: | 1790714822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REAGAN KIELE | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 S. SOLANO | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755277900 | ||||||||
| FaxNumber: | 5755714872 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 SUDDERTH | ||||||||
| Address2: | |||||||||
| City: | RUIDOSO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756300571 | ||||||||
| FaxNumber: | 5756300574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 03/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 422 | CO | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 0147561 | NM | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 18677037 | 05 | NM | MEDICAID |