Healthcare Provider Details

I. General information

NPI: 1376232934
Provider Name (Legal Business Name): INTEGRATE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ALISO DR SE
ALBUQUERQUE NM
87108-2693
US

IV. Provider business mailing address

PO BOX 36072
ALBUQUERQUE NM
87176-6072
US

V. Phone/Fax

Practice location:
  • Phone: 505-600-2314
  • Fax: 866-635-1177
Mailing address:
  • Phone: 505-600-2314
  • Fax:

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: ELIZABETH DIESEL
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 505-600-2314