Healthcare Provider Details

I. General information

NPI: 1639658149
Provider Name (Legal Business Name): TRAUMA THERAPY OF NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2018
Last Update Date: 10/12/2021
Certification Date: 10/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE L
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

1421 LUISA ST STE L
SANTA FE NM
87505-4073
US

V. Phone/Fax

Practice location:
  • Phone: 505-695-8223
  • Fax: 505-983-9846
Mailing address:
  • Phone: 505-695-8223
  • Fax: 505-983-9846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCCMH0197971
License Number StateNM

VIII. Authorized Official

Name: LAURALYN PRYOR
Title or Position: OWNER
Credential: LPCC
Phone: 505-695-8223