Healthcare Provider Details

I. General information

NPI: 1104103266
Provider Name (Legal Business Name): ANDREW CONTICELLI MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12306 MENAUL BLVD NE SUITE, C
ALBUQUERQUE NM
87112-1781
US

IV. Provider business mailing address

PO BOX 52063
ALBUQUERQUE NM
87181-2063
US

V. Phone/Fax

Practice location:
  • Phone: 505-254-1195
  • Fax:
Mailing address:
  • Phone: 505-254-1115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0115971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: