Healthcare Provider Details

I. General information

NPI: 1497561823
Provider Name (Legal Business Name): KAE MICHELLE ROJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAELUN MICHELLE BOLIVER

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 10TH AVE NE
RIO RANCHO NM
87144-4036
US

IV. Provider business mailing address

428 10TH AVE NE
RIO RANCHO NM
87144-4036
US

V. Phone/Fax

Practice location:
  • Phone: 505-859-8388
  • Fax:
Mailing address:
  • Phone: 505-859-8388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: