Healthcare Provider Details

I. General information

NPI: 1548030679
Provider Name (Legal Business Name): FUNDAMENTAL THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2024
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARQUETTE AVE NW STE 1277
ALBUQUERQUE NM
87102-5340
US

IV. Provider business mailing address

8501 VISTA SERENA LN SW
ALBUQUERQUE NM
87121-7650
US

V. Phone/Fax

Practice location:
  • Phone: 505-353-0800
  • Fax:
Mailing address:
  • Phone: 505-908-8267
  • 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: VANESSA RODRIGUEZ
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 505-353-0800