Healthcare Provider Details

I. General information

NPI: 1851809552
Provider Name (Legal Business Name): KANDI COLLIIER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 COMANCHE RD NE BUILDING E SUITE 21
ALBUQUERQUE NM
87059
US

IV. Provider business mailing address

27 JAKES PL
TIJERAS NM
87059-6301
US

V. Phone/Fax

Practice location:
  • Phone: 505-610-1439
  • Fax: 505-281-3682
Mailing address:
  • Phone: 505-610-1439
  • Fax: 505-281-3682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0193881
License Number StateNM

VIII. Authorized Official

Name: KANDI COLLIER
Title or Position: OWNER
Credential: LPCC
Phone: 505-610-1439