=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316547904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAWSITIVELY TRANSFORMATIONAL HEALTH AND WELLNESS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2020
-----------------------------------------------------
Last Update Date | 02/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 DOOLEY ST
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-8203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-404-1577
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 10TH ST # 400
-----------------------------------------------------
City | ALAMOGORDO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88310-6413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. NATHANIEL L REDEKOPP
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 575-208-6364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------