Healthcare Provider Details

I. General information

NPI: 1740996412
Provider Name (Legal Business Name): AMANDA FENN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 03/17/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 RIO GRANDE BLVD NW STE G252
ALBUQUERQUE NM
87104-2050
US

IV. Provider business mailing address

901 RIO GRANDE BLVD NW STE G252
ALBUQUERQUE NM
87104-2050
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8112
  • Fax: 505-702-8112
Mailing address:
  • Phone: 505-702-8112
  • Fax: 505-702-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2024-0167
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: