Healthcare Provider Details

I. General information

NPI: 1659026433
Provider Name (Legal Business Name): LIBERATEABQ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2022
Last Update Date: 09/06/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 GOLD AVE SW STE 1F
ALBUQUERQUE NM
87102-3119
US

IV. Provider business mailing address

609 GOLD AVE SW STE 1F
ALBUQUERQUE NM
87102-3119
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-7200
  • Fax:
Mailing address:
  • Phone: 505-758-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT THOMAS CLARK
Title or Position: OWNER
Credential: LPCC
Phone: 505-596-0614