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General NPI Number Information
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NPI Number | 1336503176
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Entity Type | Organization
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Legal Business Name | DESERT BLOOM TELEPSYCH SERVICES LLC
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Dates
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Enumeration Date | 04/07/2016
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Last Update Date | 04/07/2016
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Provider Practice Location Address
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Address Line | 8605 VINEYARD RIDGE RD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-2623
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Country | US
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Telephone | 505-620-6389
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Fax |
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Provider Business Mailing Address
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Address Line | 8605 VINEYARD RIDGE RD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-2623
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Country | US
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Telephone | 505-620-6389
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Fax |
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Authorized Official
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Title or Position | PMHNP-BC SOLE OWNER
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Name | DEBRA MARIE STANGER
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Credential | CNP
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Telephone | 505-856-2262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP-01597
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License Number State | NM
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