Healthcare Provider Details

I. General information

NPI: 1255103644
Provider Name (Legal Business Name): THERAPEUTIC ROOTS BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 04/07/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5808 MCLEOD RD NE STE P
ALBUQUERQUE NM
87109-2468
US

IV. Provider business mailing address

7900 DRAGOON RD NW
ALBUQUERQUE NM
87114-4475
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-1670
  • Fax:
Mailing address:
  • Phone: 505-228-1670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE SANDERSON
Title or Position: OWNER
Credential: LPCC
Phone: 505-228-1670