Healthcare Provider Details

I. General information

NPI: 1619256427
Provider Name (Legal Business Name): PEANUT BUTTER & JELLY FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

IV. Provider business mailing address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-7060
  • Fax:
Mailing address:
  • Phone: 505-877-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-07595
License Number StateNM

VIII. Authorized Official

Name: CAPRICE PINO
Title or Position: Q&A DIRECTOR
Credential: LADAC
Phone: 505-877-7060