Healthcare Provider Details

I. General information

NPI: 1932313400
Provider Name (Legal Business Name): GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 LAKE DR
SANTA ROSA NM
88435-2561
US

IV. Provider business mailing address

1047 LAKE DR
SANTA ROSA NM
88435-2561
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-5383
  • Fax:
Mailing address:
  • Phone: 575-472-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLISW1041C0700X
License Number StateNM

VIII. Authorized Official

Name: MR. JONAS MOYA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 505-803-4955