Healthcare Provider Details

I. General information

NPI: 1902510845
Provider Name (Legal Business Name): PRO SOCIAL THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7517 DEERFIELD RD NW
ALBUQUERQUE NM
87120-4532
US

IV. Provider business mailing address

7517 DEERFIELD RD NW
ALBUQUERQUE NM
87120-4532
US

V. Phone/Fax

Practice location:
  • Phone: 541-525-6463
  • Fax:
Mailing address:
  • Phone: 541-525-6463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: LUKE MITCHELL
Title or Position: ADMINISTRATOR
Credential: OTR/L
Phone: 505-521-0192