Healthcare Provider Details

I. General information

NPI: 1184108748
Provider Name (Legal Business Name): HEATHER HOLTER LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 PENNSYLVANIA ST NE STE E
ALBUQUERQUE NM
87110-3650
US

IV. Provider business mailing address

436 CARLISLE BLVD NE
ALBUQUERQUE NM
87106-1321
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4400
  • Fax:
Mailing address:
  • Phone: 505-453-5648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-CTL0198371
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: