Healthcare Provider Details

I. General information

NPI: 1063989648
Provider Name (Legal Business Name): UMOJA BEHAVIORAL HEALTH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3150 CARLISLE BLVD NE STE 110
ALBUQUERQUE NM
87110-1681
US

IV. Provider business mailing address

3150 CARLISLE BLVD NE STE 105
ALBUQUERQUE NM
87110-1680
US

V. Phone/Fax

Practice location:
  • Phone: 505-672-5598
  • Fax: 505-214-5071
Mailing address:
  • Phone: 505-663-8173
  • Fax: 505-672-7769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KENNETH B WINFREY
Title or Position: OWNER
Credential: LMSW
Phone: 505-663-6645