Healthcare Provider Details

I. General information

NPI: 1417711961
Provider Name (Legal Business Name): DIVINE ESSENCE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5B RUDY RODRIQUEZ DR
SANTA FE NM
87508-9220
US

IV. Provider business mailing address

1704 LLANO ST STE B-1486
SANTA FE NM
87505-5415
US

V. Phone/Fax

Practice location:
  • Phone: 505-500-4988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SARA JOHNSON
Title or Position: OWNER
Credential: LPCC, ATR
Phone: 505-500-4988