Healthcare Provider Details

I. General information

NPI: 1639004054
Provider Name (Legal Business Name): ILLIANA CRAIG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 SOUTHERN BLVD SE STE 105
RIO RANCHO NM
87124-5859
US

IV. Provider business mailing address

7320 SANTA BARBARA RD NE
ALBUQUERQUE NM
87109-6040
US

V. Phone/Fax

Practice location:
  • Phone: 505-270-0840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCBT-2026-0443
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: