Healthcare Provider Details

I. General information

NPI: 1649864695
Provider Name (Legal Business Name): JULIETTE KATRINA MCCOY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2021
Last Update Date: 02/21/2021
Certification Date: 02/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 GOLF COURSE RD NW STE 102
ALBUQUERQUE NM
87114-5917
US

IV. Provider business mailing address

9705 TAPATIO DR NW
ALBUQUERQUE NM
87114-3608
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-0808
  • Fax:
Mailing address:
  • Phone: 505-270-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10992
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: