Provider Demographics
NPI:1750774279
Name:FETROW, ELESHA KAY (LMHC NCC)
Entity type:Individual
Prefix:
First Name:ELESHA
Middle Name:KAY
Last Name:FETROW
Suffix:
Gender:F
Credentials:LMHC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8100 MOUNTAIN RD NE
Mailing Address - Street 2:SUITE 200 B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7818
Mailing Address - Country:US
Mailing Address - Phone:505-830-6500
Mailing Address - Fax:505-830-6527
Practice Address - Street 1:8100 MOUNTAIN RD NE
Practice Address - Street 2:SUITE 200 B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7818
Practice Address - Country:US
Practice Address - Phone:505-830-6500
Practice Address - Fax:505-830-6527
Is Sole Proprietor?:No
Enumeration Date:2015-03-08
Last Update Date:2015-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0169831101YM0800X
NM320424101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool