Basic Information
| Provider Information | |||||||||
| NPI: | 1649315102 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STREETWISE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4312 CARLISLE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053233785 | ||||||||
| FaxNumber: | 5053233850 | ||||||||
| Practice Location | |||||||||
| Address1: | 4312 CARLISLE BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871074811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053233785 | ||||||||
| FaxNumber: | 5053233850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MARQUEZ | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5053233785 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NM | N | Agencies | Community/Behavioral Health | 251S00000X | 600153 | NM | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | NM600153 | 05 | NM | MEDICAID |