=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710126651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARMONY FOR LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2009
-----------------------------------------------------
Last Update Date | 03/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 522 S SAINT FRANCIS DR
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-1102
-----------------------------------------------------
Fax | 505-984-1229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 522 S SAINT FRANCIS DR
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-1102
-----------------------------------------------------
Fax | 505-984-1229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARI TANKENOFF
-----------------------------------------------------
Credential | MA, LP, LPCC
-----------------------------------------------------
Telephone | 505-984-1102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | LP3024
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0112771
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------