Healthcare Provider Details

I. General information

NPI: 1679313464
Provider Name (Legal Business Name): POSITIVE POTENTIAL NM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 BARBARA LOOP SE STE 206A
RIO RANCHO NM
87124-1041
US

IV. Provider business mailing address

105 SUGAR RIDGE LOOP SE
RIO RANCHO NM
87124-4312
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-2356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: TRENT JOHN
Title or Position: CO OWNER
Credential:
Phone: 505-796-2356