Healthcare Provider Details

I. General information

NPI: 1295819662
Provider Name (Legal Business Name): IMAGING MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W 1ST STE 532
ROSWELL NM
88203
US

IV. Provider business mailing address

200 W 1ST STE 532
ROSWELL NM
88203
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-0439
  • Fax: 505-622-2750
Mailing address:
  • Phone: 505-627-0439
  • Fax: 505-622-2750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNM

VIII. Authorized Official

Name: SUSAN LEE VOIGT
Title or Position: PRESIDENT
Credential: MA ATRBC LPAT LPCC
Phone: 505-627-0439