Healthcare Provider Details

I. General information

NPI: 1710652755
Provider Name (Legal Business Name): MINDSET THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 DANTE LN NW
ALBUQUERQUE NM
87114-5024
US

IV. Provider business mailing address

PO BOX 45681
RIO RANCHO NM
87174-5681
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-7576
  • Fax:
Mailing address:
  • Phone: 505-226-1960
  • Fax: 505-672-7769

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: MARISSA DIAZ
Title or Position: OWNER
Credential: LCSW
Phone: 505-239-7576