Healthcare Provider Details

I. General information

NPI: 1639505548
Provider Name (Legal Business Name): STEPHEN LAWRENCE FORTESS LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 CENTRAL AVE NW
ALBUQUERQUE NM
87105-2036
US

IV. Provider business mailing address

6301 CENTRAL NW
ALBUQUERQUE NM
87105
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-3417
  • Fax: 505-352-3400
Mailing address:
  • Phone: 505-352-3417
  • Fax: 505-352-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0931
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: