Healthcare Provider Details

I. General information

NPI: 1790139673
Provider Name (Legal Business Name): CHANGING PERSPECTIVES YOUTH AND FAMILY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4312 CARLISLE BLVD NE
ALBUQUERQUE NM
87107-4811
US

IV. Provider business mailing address

3524 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87107-3038
US

V. Phone/Fax

Practice location:
  • Phone: 505-366-9106
  • Fax:
Mailing address:
  • Phone: 505-366-9106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC09396
License Number StateNM

VIII. Authorized Official

Name: MARY JO PICHA
Title or Position: PSYCHOTHERAPIST/SOCIAL WORKER
Credential: LCSW
Phone: 505-366-9106