Healthcare Provider Details

I. General information

NPI: 1467436790
Provider Name (Legal Business Name): MADELAINE E VAN EPP LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 ALAMO AVE SE
ALBUQUERQUE NM
87106-3204
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-2400
  • Fax: 505-925-2411
Mailing address:
  • Phone: 505-272-2312
  • Fax: 505-272-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number006970
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: