Healthcare Provider Details

I. General information

NPI: 1568991453
Provider Name (Legal Business Name): MOSSY PINE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1/2 N GRAND AVE
LAS VEGAS NM
87701-5089
US

IV. Provider business mailing address

1901 1/2 N GRAND AVE
LAS VEGAS NM
87701-5089
US

V. Phone/Fax

Practice location:
  • Phone: 505-429-7502
  • Fax:
Mailing address:
  • Phone: 505-426-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: FELICIA JACQUELINE RIVERA
Title or Position: DIRECTOR
Credential:
Phone: 505-426-6462