Healthcare Provider Details

I. General information

NPI: 1477507069
Provider Name (Legal Business Name): RIO GRANDE COUNSELING & GUIDANCE SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 LAS LOMAS RD NE SUITE 4
ALBUQUERQUE NM
87102-2634
US

IV. Provider business mailing address

2132 CENTRAL AVE SE SUITE 249
ALBUQUERQUE NM
87106-4083
US

V. Phone/Fax

Practice location:
  • Phone: 505-246-8700
  • Fax:
Mailing address:
  • Phone: 505-259-7769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04891
License Number StateNM

VIII. Authorized Official

Name: MR. JT CARRILLO
Title or Position: CEO
Credential: LISW
Phone: 505-259-7769