Healthcare Provider Details

I. General information

NPI: 1205544095
Provider Name (Legal Business Name): DESERT MAGNOLIA THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9509 PRESLEY PL NE
ALBUQUERQUE NM
87111-3401
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 505-449-7691
  • Fax: 505-672-7769
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: ALESIA CROSSLAND
Title or Position: OWNER
Credential: LCSW
Phone: 505-449-7691