Healthcare Provider Details

I. General information

NPI: 1275986457
Provider Name (Legal Business Name): JOURNEY WELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 HARKLE RD
SANTA FE NM
87505-4784
US

IV. Provider business mailing address

546 HARKLE RD
SANTA FE NM
87505-4784
US

V. Phone/Fax

Practice location:
  • Phone: 505-333-4173
  • Fax:
Mailing address:
  • Phone: 505-333-4173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0140691
License Number StateNM

VIII. Authorized Official

Name: DANA MOORE
Title or Position: OWNER
Credential: LPCC
Phone: 505-333-4173