Healthcare Provider Details

I. General information

NPI: 1730902164
Provider Name (Legal Business Name): AZOMALLI THERAPY AND GROWTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 57TH ST NW
ALBUQUERQUE NM
87105-1343
US

IV. Provider business mailing address

701 57TH ST NW
ALBUQUERQUE NM
87105-1343
US

V. Phone/Fax

Practice location:
  • Phone: 505-267-7031
  • Fax:
Mailing address:
  • Phone: 505-267-7031
  • 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: MISS DALIA MEDINA BUSTILLOS
Title or Position: OWNER
Credential: LCSW
Phone: 505-267-7031