Provider Demographics
NPI:1730126343
Name:ANDERSON, NICOLE PHOENIX (PHD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:PHOENIX
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:PHOENIX
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 66684
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87193-6684
Mailing Address - Country:US
Mailing Address - Phone:505-344-9641
Mailing Address - Fax:505-344-2621
Practice Address - Street 1:6501 4TH ST NW
Practice Address - Street 2:F4
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-5800
Practice Address - Country:US
Practice Address - Phone:505-344-9641
Practice Address - Fax:505-344-2621
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0976103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39703754Medicaid