Healthcare Provider Details

I. General information

NPI: 1548677669
Provider Name (Legal Business Name): WINDS OF CHANGE MENTAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 03/30/2023
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N 1ST ST STE B
GRANTS NM
87020-3905
US

IV. Provider business mailing address

PO BOX 178
GRANTS NM
87020-0178
US

V. Phone/Fax

Practice location:
  • Phone: 505-290-4551
  • Fax: 505-658-2398
Mailing address:
  • Phone: 505-290-4551
  • Fax: 505-658-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0034
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. RENEE H WILKINS
Title or Position: OWNER
Credential: PSYD
Phone: 505-290-4551