Healthcare Provider Details

I. General information

NPI: 1891331773
Provider Name (Legal Business Name): HEAD TO TOE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 GREENE AVE SUITE D
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

PO BOX 67098
ALBUQUERQUE NM
87193-7098
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-0057
  • Fax:
Mailing address:
  • Phone: 505-417-3824
  • 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: REBECCA L LEDEZMA-CHINCHILLA
Title or Position: CLINICAL COUNSELOR
Credential: LPCC
Phone: 505-417-3824