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General NPI Number Information
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NPI Number | 1871674887
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Entity Type | Organization
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Legal Business Name | CENTER FOR PSYCHOTHERAPEUTIC CHANGE
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Dates
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Enumeration Date | 10/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 532 DON GASPAR AVE
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City | SANTA FE
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State | NM
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Zip | 87505-2626
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Country | US
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Telephone | 505-986-3478
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Fax |
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Provider Business Mailing Address
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Address Line | 1107 CAMINITO ALEGRE
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City | SANTA FE
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State | NM
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Zip | 87501-1605
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Country | US
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Telephone | 505-986-3478
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MS. MARCELLE GRANT
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Credential | MSW
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Telephone | 505-986-3478
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | I1310
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | I1319
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License Number State | NM
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