Healthcare Provider Details

I. General information

NPI: 1396027272
Provider Name (Legal Business Name): PROFESSIONAL CONFIDENTIAL COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103A SAGAR DRIVE
VANDERWAGEN NM
87326
US

IV. Provider business mailing address

PO BOX 190
VANDERWAGEN NM
87326-0190
US

V. Phone/Fax

Practice location:
  • Phone: 505-778-5151
  • Fax: 505-778-5151
Mailing address:
  • Phone: 505-778-5177
  • Fax: 505-778-5151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0089971
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0086791
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-05565
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-2706
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0109351
License Number StateNM

VIII. Authorized Official

Name: MRS. SANDRA L SWEENEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 505-778-5151