Basic Information
| Provider Information | |||||||||
| NPI: | 1316059314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ZIA BEHAVIORAL HEALTH, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28220 | ||||||||
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| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875928220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058200262 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Practice Location | |||||||||
| Address1: | 2504 CAMINO ENTRADA | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875074851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058200262 | ||||||||
| FaxNumber: | 5058209220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 05/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | FREEDLE | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5058200262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 06-03806 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral |
ID Information
| ID | Type | State | Issuer | Description | 28178751 | 05 | NM | MEDICAID |