Healthcare Provider Details

I. General information

NPI: 1659055697
Provider Name (Legal Business Name): MS. EGLE URBONAVICIUTE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 MENAUL BLVD NE
ALBUQUERQUE NM
87112-1273
US

IV. Provider business mailing address

421 OHIO ST
SILVER CITY NM
88061-4649
US

V. Phone/Fax

Practice location:
  • Phone: 575-519-9595
  • Fax:
Mailing address:
  • Phone: 575-519-9595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: