Basic Information
| Provider Information | |||||||||
| NPI: | 1215347869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | ROSE | ||||||||
| MiddleName: | ANNA | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SAKELARES BLVD | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870203819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058761890 | ||||||||
| FaxNumber: | 5058761886 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 SAKELARES BLVD | ||||||||
| Address2: | |||||||||
| City: | GRANTS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870203819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058761890 | ||||||||
| FaxNumber: | 5058761886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2014 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T-CTL0206311 | NM | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | CCMH0225021 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.