Provider Demographics
NPI:1912253519
Name:KINKADE-BLACK, JULIET C (MFTI, PCCI)
Entity Type:Individual
Prefix:MRS
First Name:JULIET
Middle Name:C
Last Name:KINKADE-BLACK
Suffix:
Gender:F
Credentials:MFTI, PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 MOON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3935
Mailing Address - Country:US
Mailing Address - Phone:505-271-0329
Mailing Address - Fax:
Practice Address - Street 1:1709 MOON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3935
Practice Address - Country:US
Practice Address - Phone:505-271-0329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF76250101YM0800X
CAPCCI788101YM0800X
NM0181841106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health