Healthcare Provider Details

I. General information

NPI: 1093694101
Provider Name (Legal Business Name): AMANDA GRUNDSTROM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12165 NM-14 B9
CEDAR CREST NM
87008
US

IV. Provider business mailing address

3813 N POLE LOOP NE
RIO RANCHO NM
87144-5379
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-7771
  • Fax:
Mailing address:
  • Phone: 505-980-7479
  • Fax: 505-980-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: