Healthcare Provider Details

I. General information

NPI: 1235361890
Provider Name (Legal Business Name): SOUL THREADS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 08/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2074 GALISTEO ST B-3 SUITE 1
SANTA FE NM
87505
US

IV. Provider business mailing address

P O BOX 722
SANTA FE NM
87504-0722
US

V. Phone/Fax

Practice location:
  • Phone: 505-819-9434
  • Fax: 505-757-3413
Mailing address:
  • Phone: 505-819-9434
  • Fax: 505-757-3413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0120591
License Number StateNM

VIII. Authorized Official

Name: MS. LLANI MARIE MRAZ
Title or Position: OWNER
Credential: LPCC
Phone: 505-819-9434