Healthcare Provider Details

I. General information

NPI: 1669765319
Provider Name (Legal Business Name): IDEAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 CARLISLE BLVD NE
ALBUQUERQUE NM
87110-4905
US

IV. Provider business mailing address

PO BOX 81853
ALBUQUERQUE NM
87198-1853
US

V. Phone/Fax

Practice location:
  • Phone: 505-301-3820
  • Fax: 866-244-8607
Mailing address:
  • Phone: 505-301-3820
  • Fax: 866-244-8607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1158
License Number StateNM

VIII. Authorized Official

Name: MARY ANN LANDRY
Title or Position: PROVIDER
Credential: LPCC
Phone: 505-301-3820