Healthcare Provider Details

I. General information

NPI: 1386280642
Provider Name (Legal Business Name): NORTHERN COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 RANCHO SIRINGO RD UNIT 1
SANTA FE NM
87505-5530
US

IV. Provider business mailing address

2215 RANCHO SIRINGO RD UNIT 1
SANTA FE NM
87505-5530
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-8846
  • Fax:
Mailing address:
  • Phone: 505-670-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KEVIN MOELLER
Title or Position: OWNER
Credential:
Phone: 505-670-8846