=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891089280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAIN INJURY SERVICES OF NEW MEXICO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2011
-----------------------------------------------------
Last Update Date | 06/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1115 N LUNA CIR
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-989-1640
-----------------------------------------------------
Fax | 505-989-1640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 N LUNA CIR
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87501-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-989-1640
-----------------------------------------------------
Fax | 505-989-1640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. MELISSA ANN WOLF
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 505-989-1640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------