Healthcare Provider Details

I. General information

NPI: 1275924839
Provider Name (Legal Business Name): YUCCA THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 BLUE SKY LN
MESILLA PARK NM
88047-9751
US

IV. Provider business mailing address

211 BLUE SKY LN
MESILLA PARK NM
88047-9751
US

V. Phone/Fax

Practice location:
  • Phone: 575-496-0899
  • Fax: 575-377-8373
Mailing address:
  • Phone: 575-496-0899
  • Fax: 575-377-8373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI3577
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1769
License Number StateNM

VIII. Authorized Official

Name: MS. MARIA TRUJILLO
Title or Position: OWNER, SPEECH-LANGUAGE PATHOLOGIST
Credential: M.A., CCC-SLP
Phone: 575-496-0899