Healthcare Provider Details

I. General information

NPI: 1700766045
Provider Name (Legal Business Name): VITALITY MIND HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1200
ALBUQUERQUE NM
87102-5312
US

IV. Provider business mailing address

6300 CALLE AMORADA CT NW
ALBUQUERQUE NM
87114-5354
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-5121
  • Fax:
Mailing address:
  • Phone: 505-933-5121
  • 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: MS. TIFFANY DENISE TRUJILLO
Title or Position: LPCC/OWNER
Credential: MA, LPCC, NCC
Phone: 505-800-8033