MEDICARE: KEA BEHAVIORAL HEALTH, PC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1982820387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEA BEHAVIORAL HEALTH, PC

Provider Business Mailing Address
First Line	:	2812 BOSQUE DEL RIO
Second Line	:	PO BOX 27482
City	:	ALBUQUERQUE, NM 87125
State	:	NM
Zip	:	87125
Country	:	US
Telephone Number	:	505-550-3688
Fax Number	:	505-343-3130

Provider Business Practice Location Address
First Line	:	2812 BOSQUE DEL RIO LN NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-3130
Country	:	US
Telephone Number	:	505-550-3688
Fax Number	:	505-343-3130

Authorized Official
Title or Position	:	OWNER
Name	:	MS. KATHERINE ANN FIELDS
Credential	:	LPCC
Telephone Number	:	505-550-3688

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	08/22/2020

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