Healthcare Provider Details

I. General information

NPI: 1700576774
Provider Name (Legal Business Name): SKYLIGHT BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD STE 719C
SANTA FE NM
87507-2699
US

IV. Provider business mailing address

3600 CERRILLOS RD STE 719C
SANTA FE NM
87507-2699
US

V. Phone/Fax

Practice location:
  • Phone: 505-204-4252
  • Fax:
Mailing address:
  • Phone: 505-204-4252
  • 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: FERNANDO ORTIZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 575-707-8150