=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801601091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESERT THRIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2025
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36 SIERRA BLANCA
-----------------------------------------------------
City | CEDAR CREST
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87008-9445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-246-8530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36 SIERRA BLANCA
-----------------------------------------------------
City | CEDAR CREST
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87008-9445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-246-8530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. KELLY ALBONICO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 415-246-8530
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------