Healthcare Provider Details

I. General information

NPI: 1689214959
Provider Name (Legal Business Name): MIND HEART AND SOUL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 ALAMEDA BLVD NE STE A
ALBUQUERQUE NM
87113-2155
US

IV. Provider business mailing address

PO BOX 15454
RIO RANCHO NM
87174-0454
US

V. Phone/Fax

Practice location:
  • Phone: 505-220-5809
  • Fax:
Mailing address:
  • Phone: 505-220-5809
  • 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: MRS. TYRA JEAN RUSSELL FOX
Title or Position: CLINICAL MENTAL HEALTH COUNSELOR
Credential: LLPC
Phone: 505-220-5809