Provider Demographics
NPI:1194259689
Name:MAGIC LENS COUNSELING
Entity type:Organization
Organization Name:MAGIC LENS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOGERBRUGGE
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-715-2802
Mailing Address - Street 1:PO BOX 94508
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-4508
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:
Practice Address - Street 1:1124 PARK AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2941
Practice Address - Country:US
Practice Address - Phone:505-715-2802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0120991106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty