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General NPI Number Information
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NPI Number | 1063150290
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Entity Type | Organization
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Legal Business Name | CROSS ROOTS COUNSELING LLC
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 05/26/2022
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Provider Practice Location Address
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Address Line | 121 WELLESLEY DR SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-1443
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Country | US
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Telephone | 505-273-2030
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Fax |
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Provider Business Mailing Address
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Address Line | 12231 ACADEMY RD NE SUITE 301 PMB 295
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City | ALBUQUERQUE
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State | NM
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Zip | 87111
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VANESSA LOPEZ VIETS
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Credential |
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Telephone | 505-273-2030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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