Healthcare Provider Details

I. General information

NPI: 1215873690
Provider Name (Legal Business Name): BANYAN TREE MIND & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 GRANDE BLVD SE STE B2
RIO RANCHO NM
87124-1799
US

IV. Provider business mailing address

1740 GRANDE BLVD SE STE B2
RIO RANCHO NM
87124-1799
US

V. Phone/Fax

Practice location:
  • Phone: 505-551-5553
  • Fax: 949-864-1692
Mailing address:
  • Phone: 505-551-5553
  • Fax: 949-864-1692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARY RUFFANER HANSON
Title or Position: PMHNP-BC
Credential: CNP
Phone: 505-551-5553