Healthcare Provider Details

I. General information

NPI: 1003402397
Provider Name (Legal Business Name): MIND OVER MATTERS HOLISTIC WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 PALOMAS DR NE
ALBUQUERQUE NM
87110-4036
US

IV. Provider business mailing address

2424 PALOMAS DR NE
ALBUQUERQUE NM
87110-4036
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-6980
  • Fax:
Mailing address:
  • Phone: 505-459-6980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: TARA LEE THOMAS
Title or Position: COUNSELOR/OWNER
Credential: LPCC
Phone: 505-459-6980