Healthcare Provider Details

I. General information

NPI: 1497334023
Provider Name (Legal Business Name): MICHELLE SANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 DRAGOON RD NW
ALBUQUERQUE NM
87114-4475
US

IV. Provider business mailing address

7900 DRAGOON RD NW
ALBUQUERQUE NM
87114-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-1670
  • Fax:
Mailing address:
  • Phone: 505-228-1670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE SANDERSON
Title or Position: OWNER
Credential: LMHC
Phone: 505-228-1670