MEDICARE: EDOE 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center	C-09941	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2837987	OTHER	NM	SCC#

General Provider Information

NPI Number	:	1669978391
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDOE LLC

Provider Business Mailing Address
First Line	:	7430 OLD SANTA FE TRL
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-4574
Country	:	US
Telephone Number	:	505-473-6191
Fax Number	:	505-983-0833

Provider Business Practice Location Address
First Line	:	518 OLD SANTA FE TRL STE 1
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-0398
Country	:	US
Telephone Number	:	505-473-6191
Fax Number	:	505-819-1492

Authorized Official
Title or Position	:	PROVIDER
Name	:	ERIN SIBLEY DOERWALD
Credential	:	LCSW
Telephone Number	:	505-473-6191

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	04/02/2018

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Directions to “EDOE LLC ” Practice Location

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