Healthcare Provider Details

I. General information

NPI: 1194045278
Provider Name (Legal Business Name): FAMILY WORKSHOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 06/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7027 MONTGOMERY BLVD NE STE F
ALBUQUERQUE NM
87109-1589
US

IV. Provider business mailing address

7027 MONTGOMERY BLVD NE STE F
ALBUQUERQUE NM
87109-1589
US

V. Phone/Fax

Practice location:
  • Phone: 505-880-0100
  • Fax: 505-880-0102
Mailing address:
  • Phone: 505-880-0100
  • Fax: 505-880-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY BURROWS
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 505-880-0100