Healthcare Provider Details

I. General information

NPI: 1528813508
Provider Name (Legal Business Name): BEST SELF THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

2201 MENAUL BLVD NE STE A
ALBUQUERQUE NM
87107-1711
US

IV. Provider business mailing address

2201 MENAUL BLVD NE STE A
ALBUQUERQUE NM
87107-1711
US

V. Phone/Fax

Practice location:
  • Phone: 917-854-6331
  • Fax:
Mailing address:
  • Phone: 917-854-6331
  • 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: KYLE MICHAEL ROUCKUS
Title or Position: LICSW
Credential:
Phone: 505-363-3313