Basic Information
| Provider Information | |||||||||
| NPI: | 1811243579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOLFFARTH | ||||||||
| FirstName: | MICAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 5757585860 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 OAK ST | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884152530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753748326 | ||||||||
| FaxNumber: | 5757585860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | Other Service Providers | Specialist | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.