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General NPI Number Information
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NPI Number | 1386447936
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Entity Type | Organization
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Legal Business Name | IDEAL SELF THERAPY LLC
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Dates
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Enumeration Date | 03/29/2025
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Last Update Date | 03/29/2025
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Provider Practice Location Address
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Address Line | 720 8TH ST NE
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City | RIO RANCHO
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State | NM
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Zip | 87124-0791
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Country | US
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Telephone | 505-226-2191
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Fax |
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Provider Business Mailing Address
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Address Line | 1209 MOUNTAIN ROAD PL NE STE N
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-7845
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. LEAH BOGUSCH
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Credential | PHD
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Telephone | 505-226-2191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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