Healthcare Provider Details

I. General information

NPI: 1689408726
Provider Name (Legal Business Name): INNER CONNECTIONS MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 5TH ST SE
RIO RANCHO NM
87124-1467
US

IV. Provider business mailing address

1500 5TH ST SE
RIO RANCHO NM
87124-1467
US

V. Phone/Fax

Practice location:
  • Phone: 505-280-1928
  • Fax:
Mailing address:
  • Phone: 505-280-1928
  • 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: LOU DURAN
Title or Position: CREDENTIALING AND BILLING
Credential:
Phone: 505-270-3966