Provider Demographics
NPI:1720580681
Name:ARCHULETA, NICOLE CAMILLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAMILLE
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 N RAILROAD AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3159
Mailing Address - Country:US
Mailing Address - Phone:505-747-8187
Mailing Address - Fax:
Practice Address - Street 1:1227 N RAILROAD AVE STE C
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3159
Practice Address - Country:US
Practice Address - Phone:505-747-8187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0178081101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1265683049Medicaid