Healthcare Provider Details

I. General information

NPI: 1861037087
Provider Name (Legal Business Name): CARDINAL PATH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 05/10/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 1/2 S 3RD ST
RATON NM
87740-8774
US

IV. Provider business mailing address

PO BOX 1343
RATON NM
87740-1343
US

V. Phone/Fax

Practice location:
  • Phone: 575-303-2260
  • Fax: 575-303-4624
Mailing address:
  • Phone: 323-480-3710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH REBECCA BALES
Title or Position: MANAGING CLINICIAN
Credential: LCSW
Phone: 323-480-3710