Provider Demographics
NPI:1770293862
Name:PETERSON, ABIGAIL GRACE
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:GRACE
Last Name:PETERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10331 DUNBAR ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5522
Mailing Address - Country:US
Mailing Address - Phone:505-573-4242
Mailing Address - Fax:
Practice Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2050
Practice Address - Country:US
Practice Address - Phone:505-702-8112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2024-0293101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9732654268OtherHPSO