Healthcare Provider Details

I. General information

NPI: 1154773828
Provider Name (Legal Business Name): CAROL HENRY LPCC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 HARDWARE DR NE # 3
ALBUQUERQUE NM
87109-2013
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199
US

V. Phone/Fax

Practice location:
  • Phone: 505-263-6250
  • Fax:
Mailing address:
  • Phone: 505-263-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0099431
License Number StateNM

VIII. Authorized Official

Name: CAROL HENRY
Title or Position: OWNER
Credential: LPCC
Phone: 505-263-6250