Healthcare Provider Details

I. General information

NPI: 1538545462
Provider Name (Legal Business Name): SEASONS OF CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4312 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4811
US

IV. Provider business mailing address

4312 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4811
US

V. Phone/Fax

Practice location:
  • Phone: 575-322-2936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0157671
License Number StateNM

VIII. Authorized Official

Name: MS. LATITIA BROWN
Title or Position: OWNER
Credential: M.ED. LPCC
Phone: 575-322-2936