Healthcare Provider Details

I. General information

NPI: 1750737656
Provider Name (Legal Business Name): EATING DISORDERS TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE SUITE 2A
ALBUQUERQUE NM
87111-2683
US

IV. Provider business mailing address

5203 JUAN TABO BLVD NE SUITE 2A
ALBUQUERQUE NM
87111-2683
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-6121
  • Fax: 505-221-5710
Mailing address:
  • Phone: 505-266-6121
  • Fax: 505-221-5710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0454
License Number StateNM

VIII. Authorized Official

Name: KATHERINE PARAS
Title or Position: ART THERAPIST
Credential: LPAT
Phone: 505-266-6121