Healthcare Provider Details

I. General information

NPI: 1700164522
Provider Name (Legal Business Name): THE CENTRE FOR PERFORMANCE, ART, AND CULTURE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 LAS CRUCES RD
TAOS NM
87571-6577
US

IV. Provider business mailing address

PO BOX 2070
TAOS NM
87571-2070
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-1565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number91921
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number43969
License Number StateCA

VIII. Authorized Official

Name: MARJORIE MALONE
Title or Position: DIRECTOR
Credential: PH.D.,
Phone: 575-758-1565