Healthcare Provider Details

I. General information

NPI: 1033936893
Provider Name (Legal Business Name): BOUNCE BACK COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13204 BUCKSKIN RD NE
ALBUQUERQUE NM
87111-8223
US

IV. Provider business mailing address

13204 BUCKSKIN RD NE
ALBUQUERQUE NM
87111-8223
US

V. Phone/Fax

Practice location:
  • Phone: 505-373-3491
  • Fax:
Mailing address:
  • Phone: 505-373-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. WANDA LEE DURANT
Title or Position: CLINICAL DIRECTOR
Credential: LPCC
Phone: 505-328-0301