=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831573567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIAN COUNSELING AND PSYCHOTHERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2015
-----------------------------------------------------
Last Update Date | 07/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6501 4TH ST NW SUITE H-3
-----------------------------------------------------
City | LOS RANCHOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107-5800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-340-3868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 PARADISE BLVD NW # 65246
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87114-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-340-3868
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LPCC
-----------------------------------------------------
Name | GINA JIMMERSON
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-340-3868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0152551
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------