Healthcare Provider Details

I. General information

NPI: 1497410237
Provider Name (Legal Business Name): NOURISH PEDIATRIC THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2021
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2616 MCEARL AVE SE
ALBUQUERQUE NM
87106-3007
US

IV. Provider business mailing address

2616 MCEARL AVE SE
ALBUQUERQUE NM
87106-3007
US

V. Phone/Fax

Practice location:
  • Phone: 505-506-3329
  • Fax:
Mailing address:
  • Phone: 505-506-3329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANJULI ROSE SEARS
Title or Position: OWNER
Credential: MOTR/L
Phone: 505-506-3329