Healthcare Provider Details

I. General information

NPI: 1508225749
Provider Name (Legal Business Name): YOUTH SHELTERS AND FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 02/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 B AGUA FRIA STREET
SANTA FE NM
87507
US

IV. Provider business mailing address

P.O. BOX 28279
SANTA FE NM
87592-8279
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-0586
  • Fax: 505-424-0949
Mailing address:
  • Phone: 505-983-0586
  • Fax: 505-424-0949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0090881
License Number StateNM

VIII. Authorized Official

Name: MR. DAVID ALAN BLOCK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-983-0586