Healthcare Provider Details

I. General information

NPI: 1063158624
Provider Name (Legal Business Name): ORIGEN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 CAMINO DE MONTE REY SUITE A6
SANTA FE NM
87505
US

IV. Provider business mailing address

PO BOX 32526
SANTA FE NM
87594-2526
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-8010
  • Fax:
Mailing address:
  • Phone: 505-919-9734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE BURNS
Title or Position: OWNER
Credential: LCSW
Phone: 505-919-9734