Healthcare Provider Details

I. General information

NPI: 1831573567
Provider Name (Legal Business Name): CHRISTIAN COUNSELING AND PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 4TH ST NW SUITE H-3
LOS RANCHOS NM
87107-5800
US

IV. Provider business mailing address

4600 PARADISE BLVD NW # 65246
ALBUQUERQUE NM
87114-4106
US

V. Phone/Fax

Practice location:
  • Phone: 505-340-3868
  • Fax:
Mailing address:
  • Phone: 505-340-3868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0152551
License Number StateNM

VIII. Authorized Official

Name: GINA JIMMERSON
Title or Position: LPCC
Credential: LPCC
Phone: 505-340-3868