Healthcare Provider Details

I. General information

NPI: 1003898222
Provider Name (Legal Business Name): PATRICIA MARIE TELLES PH.S
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 GENE AVE NW
ALBUQUERQUE NM
87107-5405
US

IV. Provider business mailing address

652 GENE AVE NW
ALBUQUERQUE NM
87107-5405
US

V. Phone/Fax

Practice location:
  • Phone: 505-345-6772
  • Fax: 505-246-8973
Mailing address:
  • Phone: 505-345-6772
  • Fax: 505-246-8973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number.0588
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: