Healthcare Provider Details

I. General information

NPI: 1417767211
Provider Name (Legal Business Name): RADICAL HEART THERAPY AND COACHING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 NIGHT HAWK TRL
EL PRADO NM
87529-4502
US

IV. Provider business mailing address

PO BOX 1054
TAOS NM
87571-1054
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-3464
  • Fax:
Mailing address:
  • Phone: 505-670-3464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. ELOISA RAMOS
Title or Position: OWNER
Credential: LCSW
Phone: 505-670-3464