Healthcare Provider Details

I. General information

NPI: 1225509417
Provider Name (Legal Business Name): DESERT RAIN THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 12/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LOCUST ST
T OR C NM
87901-1526
US

IV. Provider business mailing address

1000 LOCUST ST
T OR C NM
87901-1526
US

V. Phone/Fax

Practice location:
  • Phone: 575-740-6101
  • Fax:
Mailing address:
  • Phone: 575-740-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARY JANE DYKE
Title or Position: MENTAL HEALTH THERAPIST
Credential: LCSW
Phone: 575-740-6101