Healthcare Provider Details

I. General information

NPI: 1417641556
Provider Name (Legal Business Name): PREMISE TO PROMISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 07/24/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 ALISO DR NE
ALBUQUERQUE NM
87108-1006
US

IV. Provider business mailing address

419 ALISO DR NE
ALBUQUERQUE NM
87108-1006
US

V. Phone/Fax

Practice location:
  • Phone: 718-490-9150
  • Fax:
Mailing address:
  • Phone: 718-490-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ERIN PADULA
Title or Position: MEMBER
Credential:
Phone: 718-490-9150