Healthcare Provider Details

I. General information

NPI: 1932373743
Provider Name (Legal Business Name): SANDIA CREST MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 US ROUTE 66 SUITE D
MORIARTY NM
87035
US

IV. Provider business mailing address

PO BOX 3823
MORIARTY NM
87035-3823
US

V. Phone/Fax

Practice location:
  • Phone: 505-384-1034
  • Fax:
Mailing address:
  • Phone: 505-463-2072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR45675
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License NumberR45675
License Number StateNM

VIII. Authorized Official

Name: MR. EDWARD RAY LOBAUGH
Title or Position: OWNDER
Credential: CNS, CNP
Phone: 505-463-2072