Healthcare Provider Details

I. General information

NPI: 1508505322
Provider Name (Legal Business Name): HEIDI S WOLNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14329 NAMBE AVE NE
ALBUQUERQUE NM
87123-1924
US

IV. Provider business mailing address

14329 NAMBE AVE NE
ALBUQUERQUE NM
87123-1924
US

V. Phone/Fax

Practice location:
  • Phone: 505-264-6131
  • Fax:
Mailing address:
  • Phone: 505-264-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberCAT4209
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: