Healthcare Provider Details

I. General information

NPI: 1467218784
Provider Name (Legal Business Name): SEALIGHT WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 CARLISLE BLVD NE STE D
ALBUQUERQUE NM
87107-4829
US

IV. Provider business mailing address

PO BOX 40742
ALBUQUERQUE NM
87196-0742
US

V. Phone/Fax

Practice location:
  • Phone: 505-519-1502
  • Fax:
Mailing address:
  • Phone:
  • 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: BOBBIE LAROCQUE
Title or Position: LCSW, OWNER
Credential:
Phone: 505-519-1502