Provider Demographics
NPI:1144767369
Name:DRUSEDUM, DYLAN OTTEMILLER (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:DYLAN
Middle Name:OTTEMILLER
Last Name:DRUSEDUM
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SERENITY HILLS PL SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-3970
Mailing Address - Country:US
Mailing Address - Phone:717-495-9004
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY BLVD NE STE 103
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2300
Practice Address - Country:US
Practice Address - Phone:505-933-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCCMH0194881101YP2500X
NM0179661101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional