Healthcare Provider Details

I. General information

NPI: 1710261797
Provider Name (Legal Business Name): DAVID EBELING LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2011
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 JUAN TABO BLVD NE STE AD
ALBUQUERQUE NM
87112-2966
US

IV. Provider business mailing address

508 TENNESSEE ST NE APT D
ALBUQUERQUE NM
87108-2356
US

V. Phone/Fax

Practice location:
  • Phone: 505-295-3159
  • Fax: 505-266-2502
Mailing address:
  • Phone: 505-331-9549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0152191
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: