Healthcare Provider Details

I. General information

NPI: 1902358674
Provider Name (Legal Business Name): KELLI HAYDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 JEFFERSON ST NE STE 360
ALBUQUERQUE NM
87109-4496
US

IV. Provider business mailing address

7601 JEFFERSON ST NE STE 360
ALBUQUERQUE NM
87109-4496
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2345
  • Fax:
Mailing address:
  • Phone: 575-769-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberX09859
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: