Healthcare Provider Details

I. General information

NPI: 1386447936
Provider Name (Legal Business Name): IDEAL SELF THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2025
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH ST NE
RIO RANCHO NM
87124-0791
US

IV. Provider business mailing address

1209 MOUNTAIN ROAD PL NE STE N
ALBUQUERQUE NM
87110-7845
US

V. Phone/Fax

Practice location:
  • Phone: 505-226-2191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. LEAH BOGUSCH
Title or Position: OWNER
Credential: PHD
Phone: 505-226-2191