Healthcare Provider Details

I. General information

NPI: 1093651663
Provider Name (Legal Business Name): SERENITY PATH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ROAD 5198
BLOOMFIELD NM
87413-9713
US

IV. Provider business mailing address

18 ROAD 5198
BLOOMFIELD NM
87413-9713
US

V. Phone/Fax

Practice location:
  • Phone: 505-289-0081
  • Fax:
Mailing address:
  • Phone: 505-289-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE MEDINA
Title or Position: OWNER/MENTAL HEALTH CLINCIAN
Credential: LPCC
Phone: 505-289-0081