Healthcare Provider Details

I. General information

NPI: 1336503176
Provider Name (Legal Business Name): DESERT BLOOM TELEPSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8605 VINEYARD RIDGE RD NE
ALBUQUERQUE NM
87122-2623
US

IV. Provider business mailing address

8605 VINEYARD RIDGE RD NE
ALBUQUERQUE NM
87122-2623
US

V. Phone/Fax

Practice location:
  • Phone: 505-620-6389
  • Fax:
Mailing address:
  • Phone: 505-620-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-01597
License Number StateNM

VIII. Authorized Official

Name: DEBRA MARIE STANGER
Title or Position: PMHNP-BC SOLE OWNER
Credential: CNP
Phone: 505-856-2262