Healthcare Provider Details

I. General information

NPI: 1881348613
Provider Name (Legal Business Name): COFFEE ON THE COUCH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 WYOMING BLVD NE
ALBUQUERQUE NM
87112-2617
US

IV. Provider business mailing address

2107 WYOMING BLVD NE
ALBUQUERQUE NM
87112-2617
US

V. Phone/Fax

Practice location:
  • Phone: 505-705-0571
  • Fax:
Mailing address:
  • Phone: 505-705-0571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TRACY HOLLINGWORTH
Title or Position: FOUNDER
Credential: LPCC
Phone: 505-705-0571