Healthcare Provider Details

I. General information

NPI: 1982127551
Provider Name (Legal Business Name): NICHOLAS CHARLES CUCCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 05/27/2024
Certification Date: 05/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 SIERRA DR SE STE 13
ALBUQUERQUE NM
87108-5633
US

IV. Provider business mailing address

1412 HERTZ DR SE
ALBUQUERQUE NM
87108-5107
US

V. Phone/Fax

Practice location:
  • Phone: 505-252-1448
  • Fax:
Mailing address:
  • Phone: 505-252-1448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberT-0190431
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: