Healthcare Provider Details

I. General information

NPI: 1891125183
Provider Name (Legal Business Name): ELEMENTAL HEALTH AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 JUAN TABO BLVD NE STE 112
ALBUQUERQUE NM
87111-2684
US

IV. Provider business mailing address

4425 JUAN TABO BLVD NE STE 112
ALBUQUERQUE NM
87111-2684
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-6800
  • Fax:
Mailing address:
  • Phone: 505-503-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0112181
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-02033
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0084711
License Number StateNM

VIII. Authorized Official

Name: ANNE CANNON
Title or Position: OWNER
Credential:
Phone: 505-503-6800