Provider Demographics
NPI:1235495979
Name:LARK'S NEST FAMILY COUNSELING CENTER
Entity Type:Organization
Organization Name:LARK'S NEST FAMILY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, BCPC, LMFT
Authorized Official - Phone:505-954-1365
Mailing Address - Street 1:422 MEDICO LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4786
Mailing Address - Country:US
Mailing Address - Phone:505-954-1365
Mailing Address - Fax:505-254-1453
Practice Address - Street 1:422 MEDICO LN
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4786
Practice Address - Country:US
Practice Address - Phone:505-954-1365
Practice Address - Fax:505-254-1453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0142451101YM0800X
103K00000X
NM0145811106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty