Healthcare Provider Details

I. General information

NPI: 1285278242
Provider Name (Legal Business Name): ALBUQUERQUE UNITED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2019
Last Update Date: 11/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 4TH ST NW STE A
ALBUQUERQUE NM
87102-1416
US

IV. Provider business mailing address

9608 BOLACK DR NE
ALBUQUERQUE NM
87109-6352
US

V. Phone/Fax

Practice location:
  • Phone: 505-331-0369
  • Fax:
Mailing address:
  • Phone: 505-331-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. BERNADETTE MILLER
Title or Position: OWNER
Credential: LMHC
Phone: 505-331-0369