Healthcare Provider Details

I. General information

NPI: 1386360691
Provider Name (Legal Business Name): WELL ROUNDED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 5TH ST NW
ALBUQUERQUE NM
87102-2137
US

IV. Provider business mailing address

828 5TH ST NW
ALBUQUERQUE NM
87102-2137
US

V. Phone/Fax

Practice location:
  • Phone: 903-271-0657
  • Fax:
Mailing address:
  • Phone: 903-271-0657
  • 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: MRS. ERIKA CARSON WILMOT
Title or Position: OWNER AND PROVIDER
Credential: LPCC
Phone: 903-271-0657