Healthcare Provider Details

I. General information

NPI: 1568259091
Provider Name (Legal Business Name): KINTSUGI BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

948 CAMINO DE LA TIERRA
CORRALES NM
87048-6909
US

IV. Provider business mailing address

948 CAMINO DE LA TIERRA
CORRALES NM
87048-6909
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-4674
  • Fax:
Mailing address:
  • Phone: 505-352-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: VYVIAN PHAN
Title or Position: CO-OWNER
Credential: LCSW
Phone: 505-702-9080