Healthcare Provider Details

I. General information

NPI: 1437740511
Provider Name (Legal Business Name): BLUE FOX WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2021
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE STE B203
ALBUQUERQUE NM
87109-1202
US

IV. Provider business mailing address

4600 MONTGOMERY BLVD NE STE B203
ALBUQUERQUE NM
87109-1202
US

V. Phone/Fax

Practice location:
  • Phone: 505-421-0814
  • Fax:
Mailing address:
  • Phone: 505-421-0814
  • 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. DIERDRE WILSON
Title or Position: OWNER
Credential: LPCC
Phone: 505-421-0814