Healthcare Provider Details

I. General information

NPI: 1518752534
Provider Name (Legal Business Name): BOLDLY RESILIENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6713 4TH ST NW
LOS RANCHOS NM
87107-6114
US

IV. Provider business mailing address

6411 CANAVIO PL NW
ALBUQUERQUE NM
87120-7052
US

V. Phone/Fax

Practice location:
  • Phone: 505-718-2119
  • Fax:
Mailing address:
  • Phone: 505-718-2119
  • 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: MRS. DOLORES RUIZ-CHAVEZ
Title or Position: PSYCHOTHERAPIST
Credential: MSW, LCSW
Phone: 505-718-2119