Healthcare Provider Details

I. General information

NPI: 1285086769
Provider Name (Legal Business Name): EARTH SPIRIT AWAKENINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST
SANTA FE NM
87505-2143
US

IV. Provider business mailing address

2019 GALISTEO ST
SANTA FE NM
87505-2143
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-8225
  • Fax: 505-930-5427
Mailing address:
  • Phone: 505-983-8225
  • Fax: 505-930-5427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1600129265
License Number StateNM

VIII. Authorized Official

Name: TOD DICECCO
Title or Position: EXECUTIVE DIRECTOR
Credential: LPCC
Phone: 505-983-8225