Healthcare Provider Details

I. General information

NPI: 1912214925
Provider Name (Legal Business Name): LEE RYEN CASTELL LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LOUISIANA BLVD NE STE C
ALBUQUERQUE NM
87110-1448
US

IV. Provider business mailing address

3901 LOUISIANA BLVD NE, SUITE C
ALBUQUERQUE NM
87110-1448
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1686
  • Fax: 505-888-1683
Mailing address:
  • Phone: 505-888-1686
  • Fax: 505-888-1683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0118101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: