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General NPI Number Information
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NPI Number | 1881911188
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Entity Type | Organization
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Legal Business Name | THE EXODUS 14/20 PSYCHOSOCIAL REHAB CENTER
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Dates
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Enumeration Date | 04/26/2010
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Last Update Date | 04/26/2010
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Provider Practice Location Address
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Address Line | 919 RIVERSIDE DRIVE
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City | ESPANOLA
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State | NM
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Zip | 87532
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Country | US
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Telephone | 505-438-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 6921 AIRPORT RD #1209
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City | SANTA FE
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State | NM
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Zip | 87507-1838
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Country | US
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Telephone | 505-438-2000
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Fax |
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Authorized Official
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Title or Position | PSYCHOSOCIAL DIRECTOR
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Name | MS. LA TONYA DELILAH WESTRICK
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Credential | BS/P CPRP
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Telephone | 505-438-2000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State | NM
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