Healthcare Provider Details

I. General information

NPI: 1356668990
Provider Name (Legal Business Name): FOUR POINT THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 EL CAMINO CAMPO
CORRALES NM
87048-7518
US

IV. Provider business mailing address

173 EL CAMINO CAMPO
CORRALES NM
87048-7518
US

V. Phone/Fax

Practice location:
  • Phone: 505-890-4117
  • Fax: 505-890-8345
Mailing address:
  • Phone: 505-890-4117
  • Fax: 505-890-8345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1591
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1591
License Number StateNM

VIII. Authorized Official

Name: MRS. DEBORA A LANPHERE
Title or Position: OCCUPATIONAL THERAPIST/OWNER
Credential:
Phone: 505-710-7668