Healthcare Provider Details

I. General information

NPI: 1669173035
Provider Name (Legal Business Name): MAQ ELE', LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 5TH ST STE O
SANTA FE NM
87505-6012
US

IV. Provider business mailing address

2800 S MEADOWS RD UNIT 435
SANTA FE NM
87507-3680
US

V. Phone/Fax

Practice location:
  • Phone: 505-913-1641
  • Fax:
Mailing address:
  • Phone: 505-913-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: MAQUEITA S ELEAZER
Title or Position: OWNER
Credential: MA, LPAT, ATR-BC
Phone: 505-913-1641