Healthcare Provider Details

I. General information

NPI: 1356121859
Provider Name (Legal Business Name): SOPHIA ARCHIBALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 201
SANTA FE NM
87507-4936
US

IV. Provider business mailing address

6A MAYAS RD
SANTA FE NM
87506-7144
US

V. Phone/Fax

Practice location:
  • Phone: 505-207-8929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2023-0261
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: