Healthcare Provider Details

I. General information

NPI: 1215267208
Provider Name (Legal Business Name): RANDALL S BERNER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 SANDIA LOOP
BERNALILLO NM
87004-7076
US

IV. Provider business mailing address

13116 VERBENA PL NE
ALBUQUERQUE NM
87112-6369
US

V. Phone/Fax

Practice location:
  • Phone: 505-771-5131
  • Fax: 505-867-7099
Mailing address:
  • Phone: 505-449-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0077121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: