Healthcare Provider Details

I. General information

NPI: 1699262428
Provider Name (Legal Business Name): MELINDA G. CARDENAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE STE 103
ALBUQUERQUE NM
87102-2300
US

IV. Provider business mailing address

115 PUEBLO LUNA DR NW
ALBUQUERQUE NM
87107-6727
US

V. Phone/Fax

Practice location:
  • Phone: 505-414-0275
  • Fax:
Mailing address:
  • Phone: 505-414-0275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number183441
License Number StateNM

VIII. Authorized Official

Name: MELINDA GAUMER CARDENAS
Title or Position: OWNER
Credential: LPCC, LPAT, ATR-BC
Phone: 505-414-0275