Healthcare Provider Details

I. General information

NPI: 1043502388
Provider Name (Legal Business Name): SANTA FE SUPPORTIVE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 LUISA ST STE 5A
SANTA FE NM
87505-4091
US

IV. Provider business mailing address

PO BOX 6623
SANTA FE NM
87502-6623
US

V. Phone/Fax

Practice location:
  • Phone: 505-926-0906
  • Fax: 505-926-0906
Mailing address:
  • Phone: 505-926-0906
  • Fax: 505-926-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06699
License Number StateNM

VIII. Authorized Official

Name: ANIKA M KELSO
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LISW
Phone: 505-926-0906