Healthcare Provider Details

I. General information

NPI: 1952593808
Provider Name (Legal Business Name): DANA WILSON VANWESTRIENEN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4686 CORRALES RD
CORRALES NM
87048-8610
US

IV. Provider business mailing address

311 WALDEN RD
CORRALES NM
87048-8379
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-4089
  • Fax:
Mailing address:
  • Phone: 505-620-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number97381
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: