=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508225749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTH SHELTERS AND FAMILY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2016
-----------------------------------------------------
Last Update Date | 02/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5686 B AGUA FRIA STREET
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-983-0586
-----------------------------------------------------
Fax | 505-424-0949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 28279
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87592-8279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-983-0586
-----------------------------------------------------
Fax | 505-424-0949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. DAVID ALAN BLOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-983-0586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 0090881
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------