Healthcare Provider Details

I. General information

NPI: 1508965021
Provider Name (Legal Business Name): LEONA K STUCKY-ABBOTT D.MIN.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 10/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 MESA VISTA ST
SANTA FE NM
87501-1732
US

IV. Provider business mailing address

140 MESA VISTA ST
SANTA FE NM
87501-1732
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-2433
  • Fax: 505-984-9974
Mailing address:
  • Phone: 505-820-2433
  • Fax: 505-984-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3020
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: