MEDICARE: KERRY J NIEC LPCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101Y00000X	Counselor	0196451	NM
3	101YM0800X	Mental Health Counselor	CCMH0196451	NM
4	101YM0800X	Mental Health Counselor	0160451	NM

General Provider Information

NPI Number	:	1104247006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY J NIEC LPCC

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:	EL CENTRO FAMILY HEALTH, 538 N. PASEO DE ONATE
City	:	ESPANOLA
State	:	NM
Zip	:	87532-0158
Country	:	US
Telephone Number	:	505-753-7218
Fax Number	:	505-753-5815

Provider Business Practice Location Address
First Line	:	2707 HOT SPRINGS BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4093
Country	:	US
Telephone Number	:	505-426-7847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2013
Last Update Date	:	08/27/2021

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