Healthcare Provider Details

I. General information

NPI: 1104595891
Provider Name (Legal Business Name): TERESA PUIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL ARTS AVE NE
ALBUQUERQUE NM
87102-2706
US

IV. Provider business mailing address

12021 SKYLINE RD NE APT 2624
ALBUQUERQUE NM
87123-3087
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-4639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0219771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: