Healthcare Provider Details

I. General information

NPI: 1851112668
Provider Name (Legal Business Name): CREATE CONNECTION COACHING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 CARGO AVE NE
ALBUQUERQUE NM
87109-6406
US

IV. Provider business mailing address

9501 CARGO AVE NE
ALBUQUERQUE NM
87109-6406
US

V. Phone/Fax

Practice location:
  • Phone: 505-582-6784
  • Fax:
Mailing address:
  • Phone: 505-582-6784
  • 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: STACY ECHEVARRIA
Title or Position: COUNSELOR
Credential: LPCC
Phone: 505-582-6784