Healthcare Provider Details

I. General information

NPI: 1720587389
Provider Name (Legal Business Name): TURQUOISE TRAIL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 STATE HIGHWAY 14 N STE B7
CEDAR CREST NM
87008-9538
US

IV. Provider business mailing address

PO BOX 86
SANDIA PARK NM
87047-0086
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-6030
  • Fax:
Mailing address:
  • Phone: 575-202-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: COURTNEY KOLB
Title or Position: OWNER
Credential: LPCC
Phone: 575-202-6030