Healthcare Provider Details

I. General information

NPI: 1154812782
Provider Name (Legal Business Name): HEART WING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2724 ALAMOSA DRIVE
SANTA FE NM
87505
US

IV. Provider business mailing address

2724 ALAMOSA DR
SANTA FE NM
87505-5234
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-8029
  • Fax:
Mailing address:
  • Phone: 512-228-8029
  • Fax: 505-213-0101

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: KIRSTEN STEVENS WING
Title or Position: OWNER
Credential: LCSW
Phone: 512-228-8029