Healthcare Provider Details

I. General information

NPI: 1194442830
Provider Name (Legal Business Name): NICOLE AVERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 COPPER AVE NE
ALBUQUERQUE NM
87108-5352
US

IV. Provider business mailing address

5101 COPPER AVE NE
ALBUQUERQUE NM
87108-5352
US

V. Phone/Fax

Practice location:
  • Phone: 505-578-2641
  • Fax:
Mailing address:
  • Phone: 505-578-2641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0436
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: