Healthcare Provider Details

I. General information

NPI: 1154147601
Provider Name (Legal Business Name): ELITE MIND AND BODY WELLNESS: MENTAL HEALTH AND PRIMARY CARE SERVICES,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 12/02/2024
Certification Date: 12/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 SHILOH RD
MESILLA PARK NM
88047-9745
US

IV. Provider business mailing address

519 SHILOH RD
MESILLA PARK NM
88047-9745
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-6367
  • Fax:
Mailing address:
  • Phone: 575-644-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. MARYBETH A PIRRONE
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: APRN, FNP, PMHNP-C
Phone: 575-644-6367