Healthcare Provider Details

I. General information

NPI: 1093694473
Provider Name (Legal Business Name): BRIGHTTRAIL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2025
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 PASEO VISTA LOOP NE
RIO RANCHO NM
87124-4526
US

IV. Provider business mailing address

128 PASEO VISTA LOOP NE
RIO RANCHO NM
87124-4526
US

V. Phone/Fax

Practice location:
  • Phone: 850-543-4938
  • Fax:
Mailing address:
  • Phone: 850-543-4938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARC W ROBSON
Title or Position: AGENT
Credential:
Phone: 850-543-4938