Healthcare Provider Details

I. General information

NPI: 1447776695
Provider Name (Legal Business Name): ASPEN VISTA THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 GALISTEO ST STE D
SANTA FE NM
87505-4781
US

IV. Provider business mailing address

1691 GALISTEO ST STE D
SANTA FE NM
87505-4781
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-1921
  • Fax: 505-983-6520
Mailing address:
  • Phone: 505-954-1921
  • Fax: 505-983-6520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number17-00146320
License Number StateNM

VIII. Authorized Official

Name: MS. LAUREL M SHAFTER
Title or Position: OWNER/OPERATOR
Credential: LCSW
Phone: 505-577-7866