=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487879631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN NAGLE HARRIS LPPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2007
-----------------------------------------------------
Last Update Date | 05/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4602 RAIL RUNNER RD
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507-0807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-0393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1704 LLANO ST # B115
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-5415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-603-0393
-----------------------------------------------------
Fax | 505-474-6980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0080601
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0080601
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------