Healthcare Provider Details

I. General information

NPI: 1669978391
Provider Name (Legal Business Name): EDOE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

518 OLD SANTA FE TRL STE 1
SANTA FE NM
87505-0398
US

IV. Provider business mailing address

7430 OLD SANTA FE TRL
SANTA FE NM
87505-4574
US

V. Phone/Fax

Practice location:
  • Phone: 505-473-6191
  • Fax: 505-819-1492
Mailing address:
  • Phone: 505-473-6191
  • Fax: 505-983-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberC-09941
License Number StateNM

VIII. Authorized Official

Name: ERIN SIBLEY DOERWALD
Title or Position: PROVIDER
Credential: LCSW
Phone: 505-473-6191