Healthcare Provider Details

I. General information

NPI: 1700277886
Provider Name (Legal Business Name): SERVICE ORGANIZATION FOR YOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 02/11/2015
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: 575-445-0540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0172211
License Number StateNM

VIII. Authorized Official

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