Healthcare Provider Details

I. General information

NPI: 1730506189
Provider Name (Legal Business Name): NICOLE GREEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE STE D-7
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

1740 GRANDE BLVD SE STE D-7
RIO RANCHO NM
87124-1799
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-1069
  • Fax: 844-714-2499
Mailing address:
  • Phone: 505-750-1069
  • Fax: 844-714-2499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0162171
License Number StateNM

VIII. Authorized Official

Name: NICOLE GREEN
Title or Position: OWNER
Credential: LPCC, NCC
Phone: 505-750-1069