Basic Information
| Provider Information | |||||||||
| NPI: | 1700114782 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAMALI | ||||||||
| FirstName: | FEREIDOUN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052728350 | ||||||||
| FaxNumber: | 5052723466 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722190 | ||||||||
| FaxNumber: | 5052723466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2009 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CCMH0165001 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1700114782 | 05 | NM | MEDICAID |