Healthcare Provider Details

I. General information

NPI: 1003938861
Provider Name (Legal Business Name): SUSAN DELORES SCROGGIN M.A., LPCC, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 2ND ST #58
SANTA FE NM
87505-3499
US

IV. Provider business mailing address

PO BOX 4501
SANTA FE NM
87502-4501
US

V. Phone/Fax

Practice location:
  • Phone: 505-995-0091
  • Fax: 505-995-0909
Mailing address:
  • Phone: 505-470-9605
  • Fax: 505-995-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0065132
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0094031
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0001063
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: