Provider Demographics
NPI:1275627937
Name:MERMILLIOD, CHRISTINE (MS LPC LMFT NCC LPCC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:MERMILLIOD
Suffix:
Gender:F
Credentials:MS LPC LMFT NCC LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1446
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-1446
Mailing Address - Country:US
Mailing Address - Phone:503-891-9858
Mailing Address - Fax:505-666-5532
Practice Address - Street 1:560 ANDREWS LN
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-9336
Practice Address - Country:US
Practice Address - Phone:503-753-6546
Practice Address - Fax:505-666-5532
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1766101Y00000X, 101YM0800X, 101YP2500X
NMCCMH0223501101YM0800X, 101Y00000X, 101YP2500X
NMCMF0223491106H00000X
ORT0482106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTS900J2RMedicaid
NM14237563Medicaid