Healthcare Provider Details

I. General information

NPI: 1497537658
Provider Name (Legal Business Name): SELF-DISCOVERY RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1052 MAIN ST NE
LOS LUNAS NM
87031-7436
US

IV. Provider business mailing address

2980 CLEAR SKY ST SW
LOS LUNAS NM
87031-6453
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-8633
  • Fax:
Mailing address:
  • Phone: 505-603-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GERASIMOS DEMOSTHENIS KLONIS
Title or Position: MANAGER
Credential: LPCC
Phone: 505-603-8633