Healthcare Provider Details

I. General information

NPI: 1891089280
Provider Name (Legal Business Name): BRAIN INJURY SERVICES OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 N LUNA CIR
SANTA FE NM
87501-1656
US

IV. Provider business mailing address

1115 N LUNA CIR
SANTA FE NM
87501-1656
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-1640
  • Fax: 505-989-1640
Mailing address:
  • Phone: 505-989-1640
  • Fax: 505-989-1640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELISSA ANN WOLF
Title or Position: DIRECTOR
Credential: LPCC
Phone: 505-989-1640