1427162460 NPI number — MS. VICKI HEINZ BLACK LMFT

Table of content: MS. VICKI HEINZ BLACK LMFT (NPI 1427162460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427162460 NPI number — MS. VICKI HEINZ BLACK LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
VICKI
Provider Middle Name:
HEINZ
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEINZ
Provider Other First Name:
VICKI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1427162460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4253 MONTGOMERY BLVD NE, SUITE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-342-0400
Provider Business Mailing Address Fax Number:
505-342-0500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4253 MONTGOMERY BLVD NE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-342-0400
Provider Business Practice Location Address Fax Number:
505-342-0500
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  0177421 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13601377 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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