Healthcare Provider Details

I. General information

NPI: 1386468577
Provider Name (Legal Business Name): LOVING EMBODIMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 E MAIN ST
TUCUMCARI NM
88401-2250
US

IV. Provider business mailing address

PO BOX 107
TUCUMCARI NM
88401-0107
US

V. Phone/Fax

Practice location:
  • Phone: 505-307-6476
  • Fax:
Mailing address:
  • Phone: 505-307-6476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CORRIANNE BRONER
Title or Position: OWNER, HEAD THERAPIST
Credential: LPCC
Phone: 505-307-6476