Healthcare Provider Details

I. General information

NPI: 1366237901
Provider Name (Legal Business Name): SOVEREIGN SELF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 WYOMING BLVD NE STE 218
ALBUQUERQUE NM
87111-3289
US

IV. Provider business mailing address

3620 WYOMING BLVD NE STE 218
ALBUQUERQUE NM
87111-3289
US

V. Phone/Fax

Practice location:
  • Phone: 720-446-6563
  • Fax:
Mailing address:
  • Phone: 308-778-7020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: NINA WILSON
Title or Position: OWNER
Credential: LPC, LPCC
Phone: 308-778-7020