Healthcare Provider Details

I. General information

NPI: 1649183799
Provider Name (Legal Business Name): WHITE WOLF PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2806 KINGS CANYON LOOP NE
RIO RANCHO NM
87144-7829
US

IV. Provider business mailing address

2806 KINGS CANYON LOOP NE
RIO RANCHO NM
87144-7829
US

V. Phone/Fax

Practice location:
  • Phone: 912-271-9437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHARA RIVERA
Title or Position: OWNER
Credential: LPCC
Phone: 912-271-9437