Healthcare Provider Details

I. General information

NPI: 1164236782
Provider Name (Legal Business Name): PAGODA BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 IRON AVE SW APT 2
ALBUQUERQUE NM
87102-3784
US

IV. Provider business mailing address

1203 IRON AVE SW APT 2
ALBUQUERQUE NM
87102-3784
US

V. Phone/Fax

Practice location:
  • Phone: 505-795-0706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: FERNANDO ORTIZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 575-707-8150