Healthcare Provider Details

I. General information

NPI: 1679786743
Provider Name (Legal Business Name): WILHELMINA THUNDERCHIEF LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 SAN MATEO BLVD NE SUITE W11B
ALBUQUERQUE NM
87110-4058
US

IV. Provider business mailing address

13170 CENTRAL AVE SE STE B STE 129
ALBUQUERQUE NM
87123-5588
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-3000
  • Fax: 505-232-3006
Mailing address:
  • Phone: 505-346-9428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0082511
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: