Healthcare Provider Details

I. General information

NPI: 1477465425
Provider Name (Legal Business Name): PROUD MOMENTS ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10511 GOLF COURSE RD NW STE 103
ALBUQUERQUE NM
87114-5917
US

IV. Provider business mailing address

10511 GOLF COURSE RD NW STE 103
ALBUQUERQUE NM
87114-5917
US

V. Phone/Fax

Practice location:
  • Phone: 505-856-6880
  • Fax:
Mailing address:
  • Phone: 505-856-6880
  • 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: BARBARA TISDALE
Title or Position: RECRUITER
Credential:
Phone: 718-215-5311