Healthcare Provider Details

I. General information

NPI: 1770293862
Provider Name (Legal Business Name): ABIGAIL GRACE PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
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

10331 DUNBAR ST NW
ALBUQUERQUE NM
87114-5522
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8112
  • Fax:
Mailing address:
  • Phone: 505-573-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2024-0293
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: