Provider Demographics
NPI:1275691891
Name:EBBERHART DURANCEAUX, NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:EBBERHART DURANCEAUX
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:EBBERHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 BROADWAY BLVD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-4624
Mailing Address - Country:US
Mailing Address - Phone:505-764-1600
Mailing Address - Fax:
Practice Address - Street 1:1501 BROADWAY BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-4624
Practice Address - Country:US
Practice Address - Phone:505-764-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist