Healthcare Provider Details

I. General information

NPI: 1992051296
Provider Name (Legal Business Name): UNMH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE BUILDING 2
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 222244
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2190
  • Fax: 505-272-3466
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA BRADY
Title or Position: SUPERVISOR LMFT
Credential:
Phone: 505-272-2190