Healthcare Provider Details

I. General information

NPI: 1184574428
Provider Name (Legal Business Name): CLEARWATER COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2026
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 CALLE CIELO VIS
BERNALILLO NM
87004-9147
US

IV. Provider business mailing address

1440 CALLE CIELO VIS
BERNALILLO NM
87004-9147
US

V. Phone/Fax

Practice location:
  • Phone: 505-278-0037
  • Fax:
Mailing address:
  • Phone: 505-278-0037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMANDA CLEARWATER
Title or Position: OWNER/COUNSELOR
Credential: LADAC, LMHC
Phone: 505-217-6834