Healthcare Provider Details

I. General information

NPI: 1174496103
Provider Name (Legal Business Name): ZAGREUS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4565
US

IV. Provider business mailing address

304 HOMELAND RD NW
ALBUQUERQUE NM
87114-1614
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-7733
  • Fax:
Mailing address:
  • Phone: 505-270-7733
  • 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: JUSTIN PETERSON
Title or Position: CLINICIAN
Credential: LPCC
Phone: 505-270-7733