Healthcare Provider Details

I. General information

NPI: 1174261515
Provider Name (Legal Business Name): KELLY PEDERSEN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 06/26/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

9108 MANRESA DR NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax: 505-896-0585
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0066
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: