Healthcare Provider Details

I. General information

NPI: 1053342659
Provider Name (Legal Business Name): CAROLYN TJOLAND LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 W ALAMEDA ST SUITE 25
SANTA FE NM
87501-1681
US

IV. Provider business mailing address

PO BOX 23302
SANTA FE NM
87502-3302
US

V. Phone/Fax

Practice location:
  • Phone: 505-955-9436
  • Fax: 505-955-9437
Mailing address:
  • Phone: 505-577-1919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC 3086
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPCC 3086
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: