Provider Demographics
NPI:1942310883
Name:ERTLE, STACY (MS, LPCC)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:ERTLE
Suffix:
Gender:F
Credentials:MS, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 CYPRESS POINT WAY NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6411
Mailing Address - Country:US
Mailing Address - Phone:505-379-1550
Mailing Address - Fax:800-714-4705
Practice Address - Street 1:6501 CYPRESS POINT WAY NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6411
Practice Address - Country:US
Practice Address - Phone:505-379-1550
Practice Address - Fax:800-714-4705
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM000105OtherVALUE OPTIONS OF NM #
11798371OtherCAQH
11798371OtherCAQH