Provider Demographics
NPI:1730506189
Name:NICOLE GREEN LLC
Entity type:Organization
Organization Name:NICOLE GREEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC, NCC
Authorized Official - Phone:505-750-1069
Mailing Address - Street 1:8205 SPAIN RD NE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3179
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:505-274-7338
Practice Address - Street 1:4111 BARBARA LOOP SE
Practice Address - Street 2:SUITE E-1
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1068
Practice Address - Country:US
Practice Address - Phone:505-750-1069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0162171101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty