Healthcare Provider Details

I. General information

NPI: 1740659804
Provider Name (Legal Business Name): TOTAH BEHAVIORAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 OJO COURT
FARMINGTON NM
87401
US

IV. Provider business mailing address

PO BOX 5190
FARMINGTON NM
87499-5190
US

V. Phone/Fax

Practice location:
  • Phone: 505-564-4804
  • Fax: 505-564-4857
Mailing address:
  • Phone: 505-564-4804
  • Fax: 505-564-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number115889273
License Number StateNM

VIII. Authorized Official

Name: URIAH DIXON SIMPSON
Title or Position: COMMUNITY SUPPORT WORKER
Credential:
Phone: 505-564-4804