Provider Demographics
NPI:1790714822
Name:REAGAN KIELE, TRACY ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:ANN
Last Name:REAGAN KIELE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S. SOLANO
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:575-527-7900
Mailing Address - Fax:575-571-4872
Practice Address - Street 1:1400 SUDDERTH
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-630-0571
Practice Address - Fax:575-630-0574
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO422106H00000X
NM0147561106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM18677037Medicaid