Healthcare Provider Details

I. General information

NPI: 1558618942
Provider Name (Legal Business Name): SANDOVAL CARPENTER COUNSELING & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 GROS VENTRE DR NE
RIO RANCHO NM
87144-7783
US

IV. Provider business mailing address

1717 GROS VENTRE DR NE
RIO RANCHO NM
87144-7783
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-6643
  • Fax:
Mailing address:
  • Phone: 505-350-6643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0080401
License Number StateNM

VIII. Authorized Official

Name: MRS. ANTOINETTE MARIE SANDOVAL CARPENTER
Title or Position: MENTAL HEALTH COUNSELOR
Credential: MA, LPCC
Phone: 505-350-6643