Basic Information
| Provider Information | |||||||||
| NPI: | 1194259689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAGIC LENS COUNSELING | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94508 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871994508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1124 PARK AVE SW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057152802 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2017 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| AuthorizedOfficialLastName: | HOOGERBRUGGE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5057152802 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 0120991 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.