Healthcare Provider Details

I. General information

NPI: 1710323829
Provider Name (Legal Business Name): SHAVANO COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 LOMAS BLVD NW
ALBUQUERQUE NM
87104-1234
US

IV. Provider business mailing address

1330 LOMAS BLVD NW
ALBUQUERQUE NM
87104-1234
US

V. Phone/Fax

Practice location:
  • Phone: 479-530-5772
  • Fax: 866-751-2593
Mailing address:
  • Phone: 479-530-5772
  • Fax: 866-751-2593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0157231
License Number StateNM

VIII. Authorized Official

Name: JOSHUA ANDERSON NEWMAN
Title or Position: COUNSELOR
Credential: LPCC
Phone: 479-530-5772