Healthcare Provider Details

I. General information

NPI: 1003140658
Provider Name (Legal Business Name): YOUTH SHELTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 AGUA FRIA ST
SANTA FE NM
87507-9001
US

IV. Provider business mailing address

5686 AGUA FRIA ST
SANTA FE NM
87507-9001
US

V. Phone/Fax

Practice location:
  • Phone: 505-438-0502
  • Fax: 505-438-0504
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM06966
License Number StateNM

VIII. Authorized Official

Name: TONI KUEHN
Title or Position: PROGRAM DIRECTOR SHELTER
Credential:
Phone: 505-438-0502