Healthcare Provider Details

I. General information

NPI: 1285303859
Provider Name (Legal Business Name): HEALING ROOTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 CARLISLE BLVD NE STE F
ALBUQUERQUE NM
87107-4532
US

IV. Provider business mailing address

4010 CARLISLE BLVD NE STE F
ALBUQUERQUE NM
87107-4532
US

V. Phone/Fax

Practice location:
  • Phone: 505-301-5297
  • Fax: 505-944-9303
Mailing address:
  • Phone: 505-301-5297
  • 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: DANIEL GONZALES
Title or Position: OWNER
Credential: LCSW
Phone: 505-720-3548