Healthcare Provider Details

I. General information

NPI: 1619536141
Provider Name (Legal Business Name): CHILD COUNSELING CENTER AND PLAY THERAPY INSTITUTE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MACLOVIA ST STE 1
SANTA FE NM
87505-3253
US

IV. Provider business mailing address

534 JUNIPER DR
SANTA FE NM
87501-1324
US

V. Phone/Fax

Practice location:
  • Phone: 505-772-0459
  • Fax:
Mailing address:
  • Phone: 505-316-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSAN BIENVENU
Title or Position: FOUNDER
Credential: MA, LPCC
Phone: 505-316-1182