=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508424987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW MEXICO CENTER FOR EMPOWERMENT AND MOOD SUPPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2019
-----------------------------------------------------
Last Update Date | 05/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11930 MENAUL BLVD NE STE 220A
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-401-0520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530B HARKLE RD # 100
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-401-0520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED CLINICAL SOCIAL WORK
-----------------------------------------------------
Name | ANDREW R DUBACH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 505-401-0520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------