Healthcare Provider Details

I. General information

NPI: 1841555406
Provider Name (Legal Business Name): STIMULATING MINDS AUTISM CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 SEAGULL ST., NE SUITE 202 B
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

6001 SEAGULL ST., NE SUITE 202 B
ALBUQUERQUE NM
87110
US

V. Phone/Fax

Practice location:
  • Phone: 505-259-2802
  • Fax: 505-892-2380
Mailing address:
  • Phone: 505-259-2802
  • Fax: 505-892-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-07820
License Number StateNM

VIII. Authorized Official

Name: MRS. JEANNE DUGGINS
Title or Position: CEO/OWNER
Credential: LISW
Phone: 505-259-2802