Healthcare Provider Details

I. General information

NPI: 1386354439
Provider Name (Legal Business Name): MICHELLE REZNIK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 TRAMWAY BLVD NE
ALBUQUERQUE NM
87112-4655
US

IV. Provider business mailing address

5805 BROKEN ARROW LN NW
ALBUQUERQUE NM
87120-3045
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6121
  • Fax:
Mailing address:
  • Phone:
  • 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:
Title or Position:
Credential:
Phone: