Provider Demographics
NPI:1164634374
Name:HILLSIDE COMMUNITY CHURCH
Entity Type:Organization
Organization Name:HILLSIDE COMMUNITY CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE MINISTER COUNSELING PROG
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:CORREU
Authorized Official - Last Name:NETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD MINISTER
Authorized Official - Phone:505-254-2606
Mailing Address - Street 1:435 JEFFERSON SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108
Mailing Address - Country:US
Mailing Address - Phone:505-254-2606
Mailing Address - Fax:
Practice Address - Street 1:435 JEFFERSON SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-254-2606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty