Healthcare Provider Details

I. General information

NPI: 1538457189
Provider Name (Legal Business Name): TRACY A. LONGWILL MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 09/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11220 JORDAN AVE NE
ALBUQUERQUE NM
87122-3383
US

IV. Provider business mailing address

11220 JORDAN AVE NE
ALBUQUERQUE NM
87122-3383
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-2715
  • Fax: 505-828-2715
Mailing address:
  • Phone: 505-828-2715
  • Fax: 505-828-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0141521
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: