Healthcare Provider Details

I. General information

NPI: 1174282909
Provider Name (Legal Business Name): SPIRIT OF HOPE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 OLD US 66
EDGEWOOD NM
87015
US

IV. Provider business mailing address

PO BOX 9
EDGEWOOD NM
87015-0009
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-2743
  • Fax:
Mailing address:
  • Phone: 505-750-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARA SHRADER
Title or Position: OWNER
Credential: LPCC
Phone: 505-750-2743