Provider Demographics
NPI:1740581511
Name:CHRYSALIS COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:CHRYSALIS COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-550-9536
Mailing Address - Street 1:808 MANZANO ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-6306
Mailing Address - Country:US
Mailing Address - Phone:505-550-9536
Mailing Address - Fax:
Practice Address - Street 1:808 MANZANO ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6306
Practice Address - Country:US
Practice Address - Phone:505-550-9536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0133481251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health