Healthcare Provider Details

I. General information

NPI: 1588200984
Provider Name (Legal Business Name): RAPHA PROVIDER AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 GUSDORF RD STE A
TAOS NM
87571-6914
US

IV. Provider business mailing address

1215 GUSDORF RD STE A
TAOS NM
87571-6914
US

V. Phone/Fax

Practice location:
  • Phone: 575-770-7139
  • Fax:
Mailing address:
  • Phone: 575-770-7139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER H WEATHERS
Title or Position: OWNER/BSC
Credential: LCSW
Phone: 575-770-7139