Healthcare Provider Details

I. General information

NPI: 1467750653
Provider Name (Legal Business Name): CASSIDY RUTH HUFFMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSIE RUTH HUFFMAN

II. Dates (important events)

Enumeration Date: 03/11/2011
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CAMINO DE VIDA SUITE 300
SANTA ROSA NM
88435
US

IV. Provider business mailing address

117 CAMINO DE VIDA SUITE 300
SANTA ROSA NM
88435
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-4311
  • Fax: 575-472-4313
Mailing address:
  • Phone: 575-472-4311
  • Fax: 575-472-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0174571
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: