Healthcare Provider Details

I. General information

NPI: 1033702360
Provider Name (Legal Business Name): SYNAPSE INTEGRATED PSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S FIRST ST
GALLUP NM
87301-6211
US

IV. Provider business mailing address

303 S FIRST ST
GALLUP NM
87301-6211
US

V. Phone/Fax

Practice location:
  • Phone: 505-397-7197
  • Fax:
Mailing address:
  • Phone: 505-488-2807
  • Fax: 844-502-0999

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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JULIANA MARIE STRAVERS
Title or Position: MEMBER/ OWNER
Credential: LLPC, LPC
Phone: 616-502-9681