Healthcare Provider Details

I. General information

NPI: 1568946358
Provider Name (Legal Business Name): SANDIA COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8416 SONOMA VALLEY RD NE
ALBUQUERQUE NM
87122-2626
US

IV. Provider business mailing address

8416 SONOMA VALLEY RD NE
ALBUQUERQUE NM
87122-2626
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-4647
  • Fax:
Mailing address:
  • Phone:
  • 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: KELLY SHANE
Title or Position: CEO
Credential: LPCC
Phone: 505-459-4647