Healthcare Provider Details

I. General information

NPI: 1871674887
Provider Name (Legal Business Name): CENTER FOR PSYCHOTHERAPEUTIC CHANGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 DON GASPAR AVE
SANTA FE NM
87505-2626
US

IV. Provider business mailing address

1107 CAMINITO ALEGRE
SANTA FE NM
87501-1605
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-3478
  • Fax:
Mailing address:
  • Phone: 505-986-3478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberI1310
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberI1319
License Number StateNM

VIII. Authorized Official

Name: MS. MARCELLE GRANT
Title or Position: VICE PRESIDENT
Credential: MSW
Phone: 505-986-3478