Healthcare Provider Details

I. General information

NPI: 1568949832
Provider Name (Legal Business Name): INESSA MIL'BERG MA, LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

28 SETON VILLAGE RD
SANTA FE NM
87508-8153
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-9360
  • Fax: 505-983-9846
Mailing address:
  • Phone: 505-670-1759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0197531
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: