Healthcare Provider Details

I. General information

NPI: 1295886372
Provider Name (Legal Business Name): SERVICE ORGANIZATION FOR YOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 05/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LETTON DR
RATON NM
87740-4366
US

IV. Provider business mailing address

PO BOX 1165
RATON NM
87740-1165
US

V. Phone/Fax

Practice location:
  • Phone: 575-445-8568
  • Fax: 575-445-0540
Mailing address:
  • Phone: 575-445-8568
  • Fax: 505-445-0540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2472
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3834
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0108891
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-06096
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0108381
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-04932
License Number StateNM
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-07045
License Number StateNM
# 8
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-06579
License Number StateNM
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-06832
License Number StateNM
# 10
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM-4177
License Number StateNM

VIII. Authorized Official

Name: MR. FERMAN L. ULIBARRI
Title or Position: EXECUTIVE DIRECTOR
Credential: LMSW
Phone: 575-445-8568