Healthcare Provider Details

I. General information

NPI: 1477244044
Provider Name (Legal Business Name): STAR RISING THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 PASEO DEL PUEBLO SUR UNIT 204
TAOS NM
87571-5974
US

IV. Provider business mailing address

208 PASEO DEL PUEBLO SUR UNIT 204
TAOS NM
87571-5974
US

V. Phone/Fax

Practice location:
  • Phone: 575-425-5485
  • Fax:
Mailing address:
  • Phone: 575-425-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ALEISA SMITH
Title or Position: LPCC/ MENTAL HEALTH COUNSELOR
Credential: LPCC
Phone: 575-425-5485