Healthcare Provider Details

I. General information

NPI: 1164588976
Provider Name (Legal Business Name): TAWN ELISE HEAD MA,LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13145 NEON AVE NE
ALBUQUERQUE NM
87112-4870
US

IV. Provider business mailing address

13145 NEON AVE NE
ALBUQUERQUE NM
87112-4870
US

V. Phone/Fax

Practice location:
  • Phone: 505-315-8001
  • Fax: 505-293-8505
Mailing address:
  • Phone: 505-315-8001
  • Fax: 505-293-8505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0087381
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: