Healthcare Provider Details

I. General information

NPI: 1700736816
Provider Name (Legal Business Name): FIREWEED THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2026
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 RIO GRANDE BLVD NW STE A
ALBUQUERQUE NM
87104-3233
US

IV. Provider business mailing address

2501 RIO GRANDE BLVD NW STE A
ALBUQUERQUE NM
87104-3233
US

V. Phone/Fax

Practice location:
  • Phone: 206-603-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: ROBERT LUCAS PEISER
Title or Position: OWNER
Credential:
Phone: 206-603-6500