Healthcare Provider Details

I. General information

NPI: 1588947113
Provider Name (Legal Business Name): NICOLE NEAL LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 BONITA ST PMS DBA WNMMG
GRANTS NM
87020-2103
US

IV. Provider business mailing address

PO BOX 217
GRANTS NM
87020-0217
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2273
  • Fax:
Mailing address:
  • Phone: 505-287-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0085381
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: