Healthcare Provider Details

I. General information

NPI: 1508395518
Provider Name (Legal Business Name): CHRYSALIS ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11930 MENAUL BLVD NE STE 225C
ALBUQUERQUE NM
87112-2465
US

IV. Provider business mailing address

11930 MENAUL BLVD NE SUITE #225C
ALBUQUERQUE NM
87048
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-4447
  • Fax: 505-323-5075
Mailing address:
  • Phone: 505-323-4447
  • Fax: 505-323-5075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number005683
License Number StateNM

VIII. Authorized Official

Name: JULIE A WATSON
Title or Position: MEMBER
Credential: LPCC
Phone: 505-323-4447