Healthcare Provider Details

I. General information

NPI: 1417066549
Provider Name (Legal Business Name): GEORGENA FELICIA LPCC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/03/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6837 GLENDORA DR NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

6837 GLENDORA DR NE
ALBUQUERQUE NM
87109
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-9661
  • Fax: 505-856-9661
Mailing address:
  • Phone: 505-350-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1697
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: