Healthcare Provider Details

I. General information

NPI: 1891056909
Provider Name (Legal Business Name): FOUR CORNERS MENTAL AND BEHAVIORAL HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 LUNA CIR NW
ALBUQUERQUE NM
87102-1973
US

IV. Provider business mailing address

PO BOX 95602
ALBUQUERQUE NM
87199
US

V. Phone/Fax

Practice location:
  • Phone: 505-504-5505
  • Fax: 505-214-5614
Mailing address:
  • Phone: 505-504-5505
  • Fax: 505-214-5614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SHANNON SOLIS BACA
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-200-9855