Healthcare Provider Details

I. General information

NPI: 1659907889
Provider Name (Legal Business Name): LIGHT ON LIFE COUNSELING & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 LUISA ST STE 5
SANTA FE NM
87505-4175
US

IV. Provider business mailing address

123 MESA VERDE ST
SANTA FE NM
87501-1729
US

V. Phone/Fax

Practice location:
  • Phone: 505-469-5577
  • Fax:
Mailing address:
  • Phone: 860-227-9264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ELLEN I PATTERSON
Title or Position: OWNER
Credential:
Phone: 860-227-9264