Healthcare Provider Details

I. General information

NPI: 1023355252
Provider Name (Legal Business Name): SANTA FE DIALECTICAL BEHAVIOR THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 SAINT MICHAELS DR SUITE 2
SANTA FE NM
87505-7655
US

IV. Provider business mailing address

411 SAINT MICHAELS DR SUITE 2
SANTA FE NM
87505-7655
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-8502
  • Fax:
Mailing address:
  • Phone: 505-983-8502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. JILL M TIEDEMANN
Title or Position: TEAM LEADER
Credential: LPCC
Phone: 505-983-8502