Healthcare Provider Details

I. General information

NPI: 1548956907
Provider Name (Legal Business Name): TRIBAL COUNSELING AND WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N THIRD ST
GALLUP NM
87301-5239
US

IV. Provider business mailing address

PO BOX 57183
ALBUQUERQUE NM
87187-7183
US

V. Phone/Fax

Practice location:
  • Phone: 505-918-7955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: FERNANDO ORTIZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 575-707-8150