Healthcare Provider Details

I. General information

NPI: 1205635091
Provider Name (Legal Business Name): CINDY KETCHUM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441 CABEZON BLVD SE STE 101
RIO RANCHO NM
87124-1576
US

IV. Provider business mailing address

6001 WHITEMAN DR NW
ALBUQUERQUE NM
87120-2196
US

V. Phone/Fax

Practice location:
  • Phone: 505-717-1155
  • Fax:
Mailing address:
  • Phone: 505-717-1155
  • Fax: 505-717-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2026-0631
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: