Healthcare Provider Details

I. General information

NPI: 1336581537
Provider Name (Legal Business Name): KAREN RENEE WENNBERG MA, LPCC, LPAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-9633
  • Fax:
Mailing address:
  • Phone: 505-986-9633
  • Fax: 505-473-3038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0173641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: