=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013833409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDIA VISTA THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2026
-----------------------------------------------------
Last Update Date | 06/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 SOMBRA DEL MONTE RD
-----------------------------------------------------
City | PLACITAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87043-8743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-364-4688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 CALLE DEL PRESIDENTE UNIT 1128
-----------------------------------------------------
City | BERNALILLO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87004-2046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-364-4688
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MORIAH CHARLENE MACCLEOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-364-4688
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------