Provider Demographics
NPI:1639210404
Name:PETTIES, KALI SUZANNE NAN (T-CTL0220451)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:SUZANNE NAN
Last Name:PETTIES
Suffix:
Gender:F
Credentials:T-CTL0220451
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8624 BLUFF SPRINGS DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2278
Mailing Address - Country:US
Mailing Address - Phone:505-681-8153
Mailing Address - Fax:505-345-2127
Practice Address - Street 1:119 INDUSTRIAL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2283
Practice Address - Country:US
Practice Address - Phone:505-345-2127
Practice Address - Fax:505-345-2127
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-CTL0220451101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor