Provider Demographics
NPI:1821585852
Name:FULFILLED CHRISTIAN COUNSELING, LLC
Entity Type:Organization
Organization Name:FULFILLED CHRISTIAN COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:206-852-7363
Mailing Address - Street 1:2870 QUASAR DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-1601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2870 QUASAR DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-1601
Practice Address - Country:US
Practice Address - Phone:206-852-7363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0188121261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)