Healthcare Provider Details

I. General information

NPI: 1043960636
Provider Name (Legal Business Name): BLUE PHOENIX THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE STE D-4
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

1740 GRANDE BLVD SE STE D-4
RIO RANCHO NM
87124-1799
US

V. Phone/Fax

Practice location:
  • Phone: 505-219-1028
  • Fax:
Mailing address:
  • Phone: 505-219-1028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ANGELA M BARELA
Title or Position: OWNER
Credential:
Phone: 505-219-1028