Healthcare Provider Details

I. General information

NPI: 1366672347
Provider Name (Legal Business Name): FREEDOM TO BE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CALLE DE LA VUELTA BLDG. D; UNIT 206
SANTA FE NM
87505-4742
US

IV. Provider business mailing address

2100 CALLE DE LA VUELTA BLDG. D; UNIT 206
SANTA FE NM
87505-4742
US

V. Phone/Fax

Practice location:
  • Phone: 505-474-6368
  • Fax: 505-474-6368
Mailing address:
  • Phone: 505-474-6368
  • Fax: 505-474-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0085671
License Number StateNM

VIII. Authorized Official

Name: MR. DARCY SULLIVAN CLARKE
Title or Position: LPCC
Credential: M.A.
Phone: 505-474-6368