Healthcare Provider Details

I. General information

NPI: 1679166946
Provider Name (Legal Business Name): ANGEL DE NIEVES GRACE ARELLANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 GIBSON BLVD SE
ALBUQUERQUE NM
87106-3348
US

IV. Provider business mailing address

PO BOX 16330
ALBUQUERQUE NM
87191-6330
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-3177
  • Fax:
Mailing address:
  • Phone: 505-219-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCMH0198631
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: