Healthcare Provider Details

I. General information

NPI: 1740679257
Provider Name (Legal Business Name): ANGELENE ABEYTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 FRIEDMAN AVE
LAS VEGAS NM
87701-4231
US

IV. Provider business mailing address

700 FRIEDMAN AVE
LAS VEGAS NM
87701-4231
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-5100
  • Fax: 505-454-0397
Mailing address:
  • Phone: 505-454-5100
  • Fax: 505-454-0397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number0134611
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: