=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518707660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AWAKENED HEART COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 CARLISLE BLVD NE STE A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-4827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-920-8938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11120 SIDNEY AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-6318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-920-8938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPCC
-----------------------------------------------------
Name | CHRISTINE KENNA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-920-8938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------