Basic Information
| Provider Information | |||||||||
| NPI: | 1316098346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC LIVING SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052685295 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052685295 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHURCH | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5052685295 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPPC | ||||||||
| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | N | Managed Care Organizations | Point of Service | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | B9311 | 05 | NM | MEDICAID |