Provider Demographics
NPI:1467830950
Name:GABRIELLE VIETHEN, MA MFA AWARE LLC
Entity type:Organization
Organization Name:GABRIELLE VIETHEN, MA MFA AWARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:505-988-1431
Mailing Address - Street 1:16 SADDLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-9398
Mailing Address - Country:US
Mailing Address - Phone:505-988-1431
Mailing Address - Fax:
Practice Address - Street 1:2074 GALISTEO ST STE B5
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2157
Practice Address - Country:US
Practice Address - Phone:505-988-1431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-15
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0708251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1245336973OtherNPI - INDIVIDUAL