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General NPI Number Information
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NPI Number | 1750773123
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Entity Type | Organization
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Legal Business Name | CARLSON EARLY CHILDHOOD MENTAL HEALTH, LLC
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Dates
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Enumeration Date | 02/23/2015
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Last Update Date | 02/23/2015
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Provider Practice Location Address
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Address Line | 4111 BARBARA LOOP SE SUITE E-1
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City | RIO RANCHO
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State | NM
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Zip | 87124-1068
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Country | US
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Telephone | 505-750-3467
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Fax |
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Provider Business Mailing Address
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Address Line | 1433 MONTIANO LOOP SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-8769
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Country | US
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Telephone | 505-250-3047
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MEGAN CARLSON
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Credential | LPCC
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Telephone | 505-250-3047
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0167751
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License Number State | NM
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