Healthcare Provider Details

I. General information

NPI: 1841942240
Provider Name (Legal Business Name): NICOLE BUNNER LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 N SCHWARTZ AVE
FARMINGTON NM
87401-5547
US

IV. Provider business mailing address

653 W ARRINGTON ST
FARMINGTON NM
87401-8513
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4584
  • Fax:
Mailing address:
  • Phone: 505-564-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCTB-2022-0700
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB20220700
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: