=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588239644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OASIS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1520 NM-94
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-617-1180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1051
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87732-1051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-617-1180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | DEIDRA CORDOVA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 505-617-1180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------