Healthcare Provider Details

I. General information

NPI: 1780385849
Provider Name (Legal Business Name): COLLECTIVE SUPPORT SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PASEO DE SAN ANTONIO
SANTA FE NM
87507-3746
US

IV. Provider business mailing address

15 PASEO DE SAN ANTONIO
SANTA FE NM
87507-3746
US

V. Phone/Fax

Practice location:
  • Phone: 505-231-8578
  • Fax:
Mailing address:
  • Phone: 505-231-8578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MELISSA MARIE MENDOZA
Title or Position: OWNER & DIRECTOR
Credential: LCSW
Phone: 505-231-8578