=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851112668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATE CONNECTION COACHING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2024
-----------------------------------------------------
Last Update Date | 11/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9501 CARGO AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-6406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-582-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9501 CARGO AVE NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-6406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-582-6784
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | STACY ECHEVARRIA
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-582-6784
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------