Healthcare Provider Details

I. General information

NPI: 1467742015
Provider Name (Legal Business Name): INTEGRATIVE PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2011
Last Update Date: 04/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 ASPEN DR STE 901B
SANTA FE NM
87505-5569
US

IV. Provider business mailing address

30 RITO GUICU
SANTA FE NM
87507-4301
US

V. Phone/Fax

Practice location:
  • Phone: 505-718-6419
  • Fax:
Mailing address:
  • Phone: 505-718-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2002-0451
License Number StateNM

VIII. Authorized Official

Name: LUIGI A DULANTO
Title or Position: PSYCHIATRIST
Credential: MD
Phone: 505-718-6419