Healthcare Provider Details

I. General information

NPI: 1841708989
Provider Name (Legal Business Name): ANGELA ANDAZOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 MONTGOMERY BLVD NE UNIT A
ALBUQUERQUE NM
87109-1210
US

IV. Provider business mailing address

301 S CAMINO DEL PUEBLO
BERNALILLO NM
87004-6276
US

V. Phone/Fax

Practice location:
  • Phone: 505-312-7958
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0214391
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: