Healthcare Provider Details

I. General information

NPI: 1225448954
Provider Name (Legal Business Name): NICK BARNECLO,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N CAMPO ST
LAS CRUCES NM
88001-3433
US

IV. Provider business mailing address

330 N CAMPO ST
LAS CRUCES NM
88001-3433
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-1110
  • Fax: 575-541-1113
Mailing address:
  • Phone: 575-541-1110
  • Fax: 575-541-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1108
License Number StateNM

VIII. Authorized Official

Name: DR. NICK BARNECLO
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 575-650-0843