Healthcare Provider Details

I. General information

NPI: 1942310883
Provider Name (Legal Business Name): STACY ERTLE MS, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 CYPRESS POINT WAY NE
ALBUQUERQUE NM
87111-6411
US

IV. Provider business mailing address

6501 CYPRESS POINT WAY NE
ALBUQUERQUE NM
87111-6411
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-1550
  • Fax: 800-714-4705
Mailing address:
  • Phone: 505-379-1550
  • Fax: 800-714-4705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: