Healthcare Provider Details

I. General information

NPI: 1023818176
Provider Name (Legal Business Name): INSIDE OUT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N RIVERSIDE DR STE 6
ESPANOLA NM
87532-2916
US

IV. Provider business mailing address

908 N RIVERSIDE DR STE 6
ESPANOLA NM
87532-2916
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-3500
  • Fax: 505-367-3503
Mailing address:
  • Phone: 505-367-3500
  • Fax: 505-367-3503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BERNADETTE GUTIERREZ
Title or Position: EXECUTIVE DIRECTOR
Credential: CPSW, CCSS, CHW
Phone: 505-367-3500