Healthcare Provider Details

I. General information

NPI: 1194259689
Provider Name (Legal Business Name): MAGIC LENS COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2017
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 PARK AVE SW
ALBUQUERQUE NM
87102-2941
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-2802
  • Fax:
Mailing address:
  • Phone: 505-384-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0120991
License Number StateNM

VIII. Authorized Official

Name: STEPHEN HOOGERBRUGGE
Title or Position: OWNER
Credential: LMFT
Phone: 505-715-2802