Healthcare Provider Details

I. General information

NPI: 1215837091
Provider Name (Legal Business Name): TENELLE M PHILLIPS, LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2026
Last Update Date: 11/06/2026
Certification Date: 11/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S 5TH ST
RATON NM
87740-4128
US

IV. Provider business mailing address

705 S 5TH ST
RATON NM
87740-4128
US

V. Phone/Fax

Practice location:
  • Phone: 575-447-0406
  • Fax: 575-447-4750
Mailing address:
  • Phone: 575-447-0406
  • Fax: 575-447-4750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TENELLE MARIE PHILLIPS
Title or Position: OWNER
Credential: LCSW
Phone: 575-447-0406