Basic Information
| Provider Information | |||||||||
| NPI: | 1730506189 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NICOLE GREEN LLC | ||||||||
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| OtherOrganizationName: | NICOLE GREEN COUNSELING & WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 SPAIN RD NE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 4111 BARBARA LOOP SE | ||||||||
| Address2: | SUITE E-1 | ||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871241068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057501069 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2014 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5057501069 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPCC, NCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0162171 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.