Healthcare Provider Details

I. General information

NPI: 1912201161
Provider Name (Legal Business Name): KATHLEEN LUELLEN CHABOT LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 4TH ST NW SUITE D
LOS RANCHOS NM
87107-6144
US

IV. Provider business mailing address

4608 ALMERIA DR NW
ALBUQUERQUE NM
87120-1840
US

V. Phone/Fax

Practice location:
  • Phone: 505-934-0934
  • Fax:
Mailing address:
  • Phone: 505-934-0934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1498
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0141941
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: