Healthcare Provider Details

I. General information

NPI: 1528544343
Provider Name (Legal Business Name): BODHI THERAPEUTIC SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2018
Last Update Date: 07/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 CENTRAL AVE NW
ALBUQUERQUE NM
87102-3007
US

IV. Provider business mailing address

709 CENTRAL AVE NW
ALBUQUERQUE NM
87102-3007
US

V. Phone/Fax

Practice location:
  • Phone: 505-907-7436
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE PARSONS
Title or Position: CFO
Credential:
Phone: 505-907-7436