Healthcare Provider Details

I. General information

NPI: 1609760115
Provider Name (Legal Business Name): HEATHER TKACZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6612 GULTON CT NE STE B
ALBUQUERQUE NM
87109-4407
US

IV. Provider business mailing address

6612 GULTON CT NE STE B
ALBUQUERQUE NM
87109-4407
US

V. Phone/Fax

Practice location:
  • Phone: 505-633-7886
  • Fax: 505-521-5165
Mailing address:
  • Phone: 505-633-7886
  • Fax: 505-521-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: