Healthcare Provider Details

I. General information

NPI: 1770078321
Provider Name (Legal Business Name): NATIVE BEHAVIORAL HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 06/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 303
SANTA FE NM
87507-4930
US

IV. Provider business mailing address

4001 OFFICE COURT DR STE 303
SANTA FE NM
87507-4930
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9456
  • Fax: 505-930-5114
Mailing address:
  • Phone: 505-395-9456
  • Fax: 505-930-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08163
License Number StateNM

VIII. Authorized Official

Name: HAL M AGLER
Title or Position: CHIEF CLINICAL OFFICER
Credential: LCSW
Phone: 505-470-5272