MEDICARE: SANTA FE SUPPORTIVE 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	1041C0700X	Clinical Social Worker	I-06699	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043502388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANTA FE SUPPORTIVE THERAPY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 6623
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87502-6623
Country	:	US
Telephone Number	:	505-926-0906
Fax Number	:	505-926-0906

Provider Business Practice Location Address
First Line	:	1418 LUISA ST STE 5A
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4091
Country	:	US
Telephone Number	:	505-926-0906
Fax Number	:	505-926-0906

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	ANIKA M KELSO
Credential	:	LISW
Telephone Number	:	505-926-0906

Provider Enumeration Date	:	05/04/2011
Last Update Date	:	01/29/2015

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