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General NPI Number Information
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NPI Number | 1366796724
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Entity Type | Organization
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Legal Business Name | NKE NEW LEAF LLC
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Dates
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Enumeration Date | 11/06/2012
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Last Update Date | 09/01/2021
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Provider Practice Location Address
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Address Line | 10921 PELLICANO DR STE 110
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City | EL PASO
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State | TX
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Zip | 79935
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Country | US
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Telephone | 915-313-4114
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Fax | 915-313-4939
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Provider Business Mailing Address
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Address Line | 10921 PELLICANO DR STE 110
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City | EL PASO
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State | TX
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Zip | 79935-4604
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Country | US
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Telephone | 915-313-4114
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Fax | 915-313-4939
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Authorized Official
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Title or Position | CEO
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Name | NOE ANTONIO LOPEZ
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Credential |
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Telephone | 915-313-4114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 66155
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License Number State | TX
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