Provider Demographics
NPI:1427162460
Name:BLACK, VICKI HEINZ (LMFT)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:HEINZ
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:
Other - Last Name:HEINZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:4253 MONTGOMERY BLVD NE, SUITE 220
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109
Mailing Address - Country:US
Mailing Address - Phone:505-342-0400
Mailing Address - Fax:505-342-0500
Practice Address - Street 1:4253 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 220
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-342-0400
Practice Address - Fax:505-342-0500
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0177421106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13601377Medicaid