MEDICARE: OUROAXIS 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1689521064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUROAXIS THERAPY, LLC

Provider Business Mailing Address
First Line	:	6000 MANTANO PLAZA DR NW
Second Line	:	APT 26D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120
Country	:	US
Telephone Number	:	505-379-4035
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000 MANTANO PLAZA DR NW
Second Line	:	APT 26D
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120
Country	:	US
Telephone Number	:	505-379-4035
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ISAAC PENNER
Credential	:	MA, LPCC
Telephone Number	:	505-379-4035

Provider Enumeration Date	:	03/13/2026
Last Update Date	:	03/13/2026

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Directions to “OUROAXIS THERAPY, LLC ” Practice Location

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