Healthcare Provider Details

I. General information

NPI: 1871788398
Provider Name (Legal Business Name): CARL DALLAS BROACH LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

IV. Provider business mailing address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

V. Phone/Fax

Practice location:
  • Phone: 505-468-1562
  • Fax:
Mailing address:
  • Phone: 505-468-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number96111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: