Healthcare Provider Details

I. General information

NPI: 1205295524
Provider Name (Legal Business Name): IRINI GEORGAS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 ISLETA BLVD SW
ALBUQUERQUE NM
87105-4035
US

IV. Provider business mailing address

1218 SUMMER AVE NW
ALBUQUERQUE NM
87104-2158
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-7296
  • Fax:
Mailing address:
  • Phone: 505-850-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0179431
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: