=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740581511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRYSALIS COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2010
-----------------------------------------------------
Last Update Date | 11/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 MANZANO ST NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-550-9536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 MANZANO ST NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-550-9536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. KELLY ANNETTE BROOKS
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-550-9536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0133481
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------