Healthcare Provider Details

I. General information

NPI: 1629009899
Provider Name (Legal Business Name): SU VIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601A SAINT MICHAELS DR
SANTA FE NM
87505-7614
US

IV. Provider business mailing address

1601A SAINT MICHAELS DR
SANTA FE NM
87505-7614
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-8777
  • Fax: 505-954-8793
Mailing address:
  • Phone: 505-954-8777
  • Fax: 505-954-8793

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: CAROL J FITZPATRICK
Title or Position: EXECUTIVE DIRECTOR/CEO
Credential: PHD
Phone: 505-954-8777