Healthcare Provider Details

I. General information

NPI: 1558774034
Provider Name (Legal Business Name): CHARLEEN YORK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 11/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE STE 2A
ALBUQUERQUE NM
87111-2691
US

IV. Provider business mailing address

12509 PHOENIX AVE NE
ALBUQUERQUE NM
87112-2527
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-6338
  • Fax: 505-221-5710
Mailing address:
  • Phone: 505-702-1703
  • Fax: 505-221-5710

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: