Healthcare Provider Details

I. General information

NPI: 1245417104
Provider Name (Legal Business Name): PUEBLO OF ISLETA BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH ST
ISLETA NM
87022-0000
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4863
  • Fax: 505-869-4881
Mailing address:
  • Phone: 505-869-4863
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateNM

VIII. Authorized Official

Name: BARBARTA A MONTANO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 505-869-4863