Healthcare Provider Details

I. General information

NPI: 1710630231
Provider Name (Legal Business Name): RIO ARRIBA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 INDUSTRIAL PARK RD STE B
ESPANOLA NM
87532-2629
US

IV. Provider business mailing address

1122 INDUSTRIAL PARK RD
ESPANOLA NM
87532-3453
US

V. Phone/Fax

Practice location:
  • Phone: 505-747-1418
  • Fax:
Mailing address:
  • Phone: 505-747-1418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMBER LEICHTLE
Title or Position: CLINICAL DIRECTOR
Credential: LCSW LADAC
Phone: 505-747-1418