MEDICARE: SANTA FE DIALECTICAL BEHAVIOR THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1023355252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA FE DIALECTICAL BEHAVIOR THERAPY, LLC

Provider Business Mailing Address
First Line	:	411 SAINT MICHAELS DR
Second Line	:	SUITE 2
City	:	SANTA FE
State	:	NM
Zip	:	87505-7655
Country	:	US
Telephone Number	:	505-983-8502
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 SAINT MICHAELS DR
Second Line	:	SUITE 2
City	:	SANTA FE
State	:	NM
Zip	:	87505-7655
Country	:	US
Telephone Number	:	505-983-8502
Fax Number	:

Authorized Official
Title or Position	:	TEAM LEADER
Name	:	MS. JILL M TIEDEMANN
Credential	:	LPCC
Telephone Number	:	505-983-8502

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	06/09/2016

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