Healthcare Provider Details

I. General information

NPI: 1013470780
Provider Name (Legal Business Name): TESSA'S THERAPIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 DE RODRIGUEZ LN.
SAN MIGUEL NM
88058
US

IV. Provider business mailing address

PO BOX 405
SAN MIGUEL NM
88058-0405
US

V. Phone/Fax

Practice location:
  • Phone: 575-644-9861
  • Fax:
Mailing address:
  • Phone: 575-644-9861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: THERESA A. ONTIVEROS
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 575-644-9861