Healthcare Provider Details

I. General information

NPI: 1548704083
Provider Name (Legal Business Name): ANN PETERSEN COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 12/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 CORRALES RD SUITE #3
CORRALES NM
87048-8610
US

IV. Provider business mailing address

PO BOX 3237
CORRALES NM
87048-3237
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9913
  • Fax:
Mailing address:
  • Phone: 505-400-9913
  • Fax: 505-890-1527

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0119911
License Number StateNM

VIII. Authorized Official

Name: ANN R PETERSEN
Title or Position: LPCC
Credential:
Phone: 505-400-9913