Healthcare Provider Details

I. General information

NPI: 1346476009
Provider Name (Legal Business Name): SALLY CARLON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LOUISIANA BLVD NE SUITE C
ALBUQUERQUE NM
87110-1577
US

IV. Provider business mailing address

9217 GALAXIA WAY NE
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1686
  • Fax: 505-888-1683
Mailing address:
  • Phone: 505-681-3819
  • Fax: 505-888-1686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0154131
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: