Healthcare Provider Details

I. General information

NPI: 1083185128
Provider Name (Legal Business Name): ENLIGHTENMENT COUNSELING & THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE A4
ALBUQUERQUE NM
87110-1391
US

IV. Provider business mailing address

2912 THOMPSON LN SW
ALBUQUERQUE NM
87105-4434
US

V. Phone/Fax

Practice location:
  • Phone: 505-710-5188
  • Fax:
Mailing address:
  • Phone: 505-710-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARK ORTEGA
Title or Position: OWNER
Credential: LCSW
Phone: 505-710-5188