Healthcare Provider Details

I. General information

NPI: 1063957983
Provider Name (Legal Business Name): MADELEINE N STEVENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2017
Last Update Date: 01/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CAMINO DEL PUEBLO
BERNALILLO NM
87004-6276
US

IV. Provider business mailing address

9 CAMINO DE SAN FELIPE
PLACITAS NM
87043-9388
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-5281
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0106661
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0121691
License Number StateNM

VIII. Authorized Official

Name: MADELEINE NOEL STEVENS
Title or Position: OWNER/PSYCHOTHERAPIST
Credential:
Phone: 505-385-5281