=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669536124
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOX THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 02/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3212 MONTE VISTA BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-2120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-266-0388
-----------------------------------------------------
Fax | 505-268-1063
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 9TH ST NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-3026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-266-0388
-----------------------------------------------------
Fax | 505-268-1063
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NATHAN FOX
-----------------------------------------------------
Credential | LISW
-----------------------------------------------------
Telephone | 505-266-0388
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | I-05588
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------