Basic Information
| Provider Information | |||||||||
| NPI: | 1578831780 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW MEXICO BEHAVIORAL HEALTH INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3695 HOT SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877019549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054545100 | ||||||||
| FaxNumber: | 5054545172 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 FRIEDMAN AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 877014231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054545100 | ||||||||
| FaxNumber: | 5054545172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2011 | ||||||||
| LastUpdateDate: | 12/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | DOMINGUEZ | ||||||||
| AuthorizedOfficialFirstName: | CORINNE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CBS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5054545134 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF NEW MEXICO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | M-07539 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.