Healthcare Provider Details

I. General information

NPI: 1508488677
Provider Name (Legal Business Name): NEW MEXICO TEEN CHALLENGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 07/07/2023
Certification Date: 07/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAMINO ORO CT
TIJERAS NM
87059-7924
US

IV. Provider business mailing address

PO BOX 20610
ALBUQUERQUE NM
87154-0610
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-8731
  • Fax: 706-596-8732
Mailing address:
  • Phone: 706-596-8731
  • Fax: 706-596-8732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: JAMES GOINS JR.
Title or Position: CLINICAL SUPERVISOR
Credential:
Phone: 484-868-0584