Healthcare Provider Details

I. General information

NPI: 1508424987
Provider Name (Legal Business Name): NEW MEXICO CENTER FOR EMPOWERMENT AND MOOD SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11930 MENAUL BLVD NE STE 220A
ALBUQUERQUE NM
87112-2461
US

IV. Provider business mailing address

530B HARKLE RD # 100
SANTA FE NM
87505-4739
US

V. Phone/Fax

Practice location:
  • Phone: 505-401-0520
  • Fax:
Mailing address:
  • Phone: 505-401-0520
  • 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: ANDREW R DUBACH
Title or Position: OWNER/LICENSED CLINICAL SOCIAL WORK
Credential: LCSW
Phone: 505-401-0520