Provider Demographics
NPI:1952439424
Name:ACKLEN, CHRISTINE R (LISW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:R
Last Name:ACKLEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LOUISIANA BLVD SE
Mailing Address - Street 2:VAN BUREN MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3847
Mailing Address - Country:US
Mailing Address - Phone:505-268-3833
Mailing Address - Fax:
Practice Address - Street 1:700 LOUISIANA BLVD SE
Practice Address - Street 2:VAN BUREN MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3847
Practice Address - Country:US
Practice Address - Phone:505-268-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI 05882104100000X
NMI058821041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88628736Medicaid