Healthcare Provider Details

I. General information

NPI: 1780430181
Provider Name (Legal Business Name): HEARTSPACE NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 MILLERS END
SANTA FE NM
87508-9405
US

IV. Provider business mailing address

14 MILLERS END
SANTA FE NM
87508-9405
US

V. Phone/Fax

Practice location:
  • Phone: 214-676-3879
  • Fax: 214-292-9313
Mailing address:
  • Phone: 214-676-3879
  • Fax: 214-292-9313

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: SHARI H SCOTT
Title or Position: MEMBER
Credential: PMHNP-BC
Phone: 214-676-3879