Healthcare Provider Details

I. General information

NPI: 1356733158
Provider Name (Legal Business Name): SOUTHWEST PUEBLO CONSULTANTS AND COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 SAN PEDRO CT NE
ALBUQUERQUE NM
87109-2515
US

IV. Provider business mailing address

5020 SAN PEDRO CT NE
ALBUQUERQUE NM
87109-2515
US

V. Phone/Fax

Practice location:
  • Phone: 505-554-8302
  • Fax: 505-881-2646
Mailing address:
  • Phone: 505-554-8302
  • Fax: 505-881-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberFAO117647
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberFA0117647
License Number StateNM

VIII. Authorized Official

Name: MISS ROCHELLE ROBYN ATENCIO
Title or Position: BEHAVIORAL HEALTH THERAPIST
Credential: LISW
Phone: 505-554-8302