Healthcare Provider Details

I. General information

NPI: 1316325061
Provider Name (Legal Business Name): SERENITY WELLNESS CENTER OF SANTA FE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 E PALACE AVE
SANTA FE NM
87501
US

IV. Provider business mailing address

1000 CORDOVA PLACE #411
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-690-3134
  • Fax: 505-216-2616
Mailing address:
  • Phone: 505-690-3134
  • Fax: 505-216-2616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0094521
License Number StateNM

VIII. Authorized Official

Name: ALISHA NICOLE SHELBOURN
Title or Position: OWNER
Credential: MA, LPAT
Phone: 505-690-3134