Healthcare Provider Details

I. General information

NPI: 1134406036
Provider Name (Legal Business Name): CHRISTINE KENNA MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 SAN PEDRO DR NE STE 102
ALBUQUERQUE NM
87110-4197
US

IV. Provider business mailing address

1304 KIRBY ST NE
ALBUQUERQUE NM
87112-4540
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-7721
  • Fax: 678-426-6620
Mailing address:
  • Phone: 505-293-5576
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0990
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: