Healthcare Provider Details

I. General information

NPI: 1053020123
Provider Name (Legal Business Name): PHOENIX SUPPORTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 21ST ST SE STE B
RIO RANCHO NM
87124-4030
US

IV. Provider business mailing address

PO BOX 15248
RIO RANCHO NM
87174-0248
US

V. Phone/Fax

Practice location:
  • Phone: 505-353-2061
  • Fax:
Mailing address:
  • Phone: 505-353-2061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RAQUEL GUZMAN VEGA
Title or Position: OWNER
Credential: LMSW
Phone: 505-353-2061