Provider Demographics
NPI:1528501079
Name:FOSSUM, EMILY (LPCC)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:FOSSUM
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:MARIA
Other - Last Name:RAFFEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC
Mailing Address - Street 1:835 SPRUCE ST STE C&D
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-3455
Mailing Address - Country:US
Mailing Address - Phone:505-747-7400
Mailing Address - Fax:505-747-7403
Practice Address - Street 1:835 SPRUCE ST STE C&D
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-3455
Practice Address - Country:US
Practice Address - Phone:505-747-7400
Practice Address - Fax:505-747-7403
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01318101YP2500X
101YP2500X
NMCCMH0224041101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional