Healthcare Provider Details

I. General information

NPI: 1730126343
Provider Name (Legal Business Name): NICOLE PHOENIX ANDERSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE PHOENIX GIBSON PHD

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 4TH ST NW F4
LOS RANCHOS NM
87107-5800
US

IV. Provider business mailing address

PO BOX 66684
ALBUQUERQUE NM
87193-6684
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-9641
  • Fax: 505-344-2621
Mailing address:
  • Phone: 505-344-9641
  • Fax: 505-344-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0976
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: