Healthcare Provider Details

I. General information

NPI: 1285088963
Provider Name (Legal Business Name): HOZHO CENTER FOR PERSONAL ENHANCEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 11/20/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 W HISTORIC HWY 66 ROOM 1203
GALLUP NM
87301
US

IV. Provider business mailing address

PO BOX 3809
GALLUP NM
87305-9998
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-1483
  • Fax: 505-870-1483
Mailing address:
  • Phone: 505-330-1885
  • Fax: 505-870-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-0777
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0180441
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number486
License Number StateNM

VIII. Authorized Official

Name: KEN COLLINS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-330-1885