Healthcare Provider Details

I. General information

NPI: 1164633541
Provider Name (Legal Business Name): COMMUNITY SERVICES TRAINING INSTITUTE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 TIJERAS AVE NW
ALBUQUERQUE NM
87102-3096
US

IV. Provider business mailing address

PO BOX 7065
ALBUQUERQUE NM
87194-7065
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-2223
  • Fax: 505-243-3576
Mailing address:
  • Phone: 505-243-2223
  • Fax: 505-243-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: KEN WELLS
Title or Position: CLINICAL DIRECTOR
Credential: PH.D
Phone: 505-243-2223