=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841418019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST PSYCHOTHERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4810 HARDWARE DR NE SUITE 5
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-830-1200
-----------------------------------------------------
Fax | 505-830-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 560 BERRY RD NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-830-1200
-----------------------------------------------------
Fax | 505-830-1203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SUSAN LANE
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-830-1200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------