=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407730609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THIRD WAVE PSYCHOTHERAPY OF NEW MEXICO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2025
-----------------------------------------------------
Last Update Date | 08/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10400 ACADEMY RD NE STE 345
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-7351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-345-6100
-----------------------------------------------------
Fax | 505-212-0042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10400 ACADEMY RD NE STE 345
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87111-7351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-345-6100
-----------------------------------------------------
Fax | 505-212-0042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAE LITTLEWOOD
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 505-977-7972
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------