Healthcare Provider Details

I. General information

NPI: 1508221938
Provider Name (Legal Business Name): TRAA GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2906 HILLRISE DR
LAS CRUCES NM
88011
US

IV. Provider business mailing address

2906 HILLRISE DR
LAS CRUCES NM
88011-4702
US

V. Phone/Fax

Practice location:
  • Phone: 575-652-3646
  • Fax: 575-288-1625
Mailing address:
  • Phone: 575-652-3646
  • Fax: 575-288-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-09387
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberCNP-02575
License Number StateNM

VIII. Authorized Official

Name: TALLY MAY
Title or Position: OWNER
Credential:
Phone: 575-652-3646