Healthcare Provider Details

I. General information

NPI: 1295371714
Provider Name (Legal Business Name): RISE UP NEW MEXICO BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8815 TRADEWIND RD NW
ALBUQUERQUE NM
87121-7021
US

IV. Provider business mailing address

8815 TRADEWIND RD NW
ALBUQUERQUE NM
87121-7021
US

V. Phone/Fax

Practice location:
  • Phone: 505-604-1244
  • Fax:
Mailing address:
  • Phone: 505-604-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS J PUTNAM
Title or Position: OWNER
Credential: LCSW
Phone: 505-604-1244