Healthcare Provider Details

I. General information

NPI: 1861886632
Provider Name (Legal Business Name): SOUTH WEST HEALING AND CHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1424 DEBORAH ROAD SE
RIO RANCHO NM
87124
US

IV. Provider business mailing address

8205 SPAIN ROAD NE SUITE 106
ALBUQUERQUE NM
87109-3155
US

V. Phone/Fax

Practice location:
  • Phone: 505-415-8085
  • Fax:
Mailing address:
  • Phone: 505-384-7352
  • Fax: 505-274-7338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0146921
License Number StateNM

VIII. Authorized Official

Name: MAUREEN BRICKLEY
Title or Position: LPCC/OWNER
Credential:
Phone: 215-803-5261