Healthcare Provider Details

I. General information

NPI: 1396011086
Provider Name (Legal Business Name): TILLIE SUE WORRELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2218 SOUTHERN BLVD SE STE 14
RIO RANCHO NM
87124-3750
US

IV. Provider business mailing address

7700 HARRIER AVE NW
ALBUQUERQUE NM
87114-4442
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-0161
  • Fax:
Mailing address:
  • Phone: 505-659-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: