Healthcare Provider Details

I. General information

NPI: 1164579082
Provider Name (Legal Business Name): PB & J FAMILY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 LOPEZ RD SW
ALBUQUERQUE NM
87105-3954
US

IV. Provider business mailing address

1101 LOPEZ SW
ALBUQUERQUE NM
87105
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-7060
  • Fax: 505-877-7063
Mailing address:
  • Phone: 505-877-7060
  • Fax: 505-877-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNM
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSANNAH BURKE
Title or Position: EXEC. DIRECTOR
Credential: MS, MSW, LISW
Phone: 505-877-7060