Healthcare Provider Details

I. General information

NPI: 1710460126
Provider Name (Legal Business Name): EAGLE ROCK THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 CAGUA DR NE
ALBUQUERQUE NM
87110-6612
US

IV. Provider business mailing address

1608 CAGUA DR NE
ALBUQUERQUE NM
87110-6612
US

V. Phone/Fax

Practice location:
  • Phone: 323-627-1469
  • Fax:
Mailing address:
  • Phone: 323-627-1469
  • 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: MS. DAMARIS ROBIN MARTINEZ
Title or Position: PSYCHOTHERAPIST
Credential: LMFT
Phone: 323-627-1469