Healthcare Provider Details

I. General information

NPI: 1205675154
Provider Name (Legal Business Name): PASSIONATE MINDS BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 OSPREY CT
SANTA TERESA NM
88008-9502
US

IV. Provider business mailing address

185 OSPREY CT
SANTA TERESA NM
88008-9502
US

V. Phone/Fax

Practice location:
  • Phone: 915-701-6864
  • Fax:
Mailing address:
  • Phone: 915-701-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW BRYAN
Title or Position: OWNER
Credential: LCSW
Phone: 915-701-6864