Healthcare Provider Details

I. General information

NPI: 1043640493
Provider Name (Legal Business Name): KRISTIN LICHTLE LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 CARLISLE BLVD NE STE G
ALBUQUERQUE NM
87107-4566
US

IV. Provider business mailing address

3825 MONTGOMERY BLVD NE APT 121
ALBUQUERQUE NM
87109-1007
US

V. Phone/Fax

Practice location:
  • Phone: 505-588-8207
  • Fax:
Mailing address:
  • Phone: 505-588-8207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0733
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: