Healthcare Provider Details

I. General information

NPI: 1992418370
Provider Name (Legal Business Name): DYNAMIC THERAPY SERVICES OF NORTHERN NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 12/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 LUISA ST STE 7
SANTA FE NM
87505-4177
US

IV. Provider business mailing address

50 VERANO LOOP
SANTA FE NM
87508-8827
US

V. Phone/Fax

Practice location:
  • Phone: 505-636-6550
  • Fax:
Mailing address:
  • Phone: 505-629-6853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. BENJAMIN GREENBERG
Title or Position: OWNER/DIRECTOR
Credential: PSYD
Phone: 505-636-6550