Healthcare Provider Details

I. General information

NPI: 1003494303
Provider Name (Legal Business Name): COTTONWOOD THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 11/29/2024
Certification Date: 11/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 LOUISIANA BLVD NE STE H
ALBUQUERQUE NM
87110-3565
US

IV. Provider business mailing address

1800 GEORGIA ST NE
ALBUQUERQUE NM
87110-5903
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-1260
  • Fax:
Mailing address:
  • Phone: 505-459-1260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN R. WILLOUGHBY
Title or Position: LCSW, OWNER
Credential: LCSW
Phone: 505-459-1260