Healthcare Provider Details

I. General information

NPI: 1194495200
Provider Name (Legal Business Name): EXPRESSIVE ARTS PROJECT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CENTRAL PARK SQ STE 215
LOS ALAMOS NM
87544-4004
US

IV. Provider business mailing address

190 CENTRAL PARK SQ STE 215
LOS ALAMOS NM
87544-4004
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-7585
  • Fax:
Mailing address:
  • Phone: 505-273-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DIANA TORRES
Title or Position: OWNER/COUNSELOR/CONSULTANT
Credential: LPCC
Phone: 505-273-7585