Healthcare Provider Details

I. General information

NPI: 1972626463
Provider Name (Legal Business Name): LABYRINTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 CERRILLOS RD
SANTA FE NM
87501-3784
US

IV. Provider business mailing address

14 MELADO DR
SANTA FE NM
87508-2254
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-0641
  • Fax:
Mailing address:
  • Phone: 505-603-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4706
License Number StateNM

VIII. Authorized Official

Name: DR. LAWRENCE ELDEN DETTWEILER
Title or Position: MANAGER
Credential: PH.D.
Phone: 505-603-0641