Healthcare Provider Details

I. General information

NPI: 1578791554
Provider Name (Legal Business Name): CARLY RENEE SEDGWICK M.S., ED.S., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 BOBCAT BLVD NE
ALBUQUERQUE NM
87122-1335
US

IV. Provider business mailing address

937 BOBCAT BLVD NE
ALBUQUERQUE NM
87122-1335
US

V. Phone/Fax

Practice location:
  • Phone: 505-850-3696
  • Fax:
Mailing address:
  • Phone: 505-850-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0014090
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0156261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: