Healthcare Provider Details

I. General information

NPI: 1710635388
Provider Name (Legal Business Name): JOURNEY OF HOPE AND COURAGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/30/2022
Certification Date: 03/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 SARATOGA DR NE
RIO RANCHO NM
87124-4624
US

IV. Provider business mailing address

1380 RIO RANCHO BLVD #107
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-595-7093
  • Fax:
Mailing address:
  • Phone: 505-595-7093
  • 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: NATHAN INTERIAL
Title or Position: OWNER
Credential: LPCC
Phone: 505-595-7093