Basic Information
| Provider Information | |||||||||
| NPI: | 1760051130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEAMBUILDERS BEHAVIORAL HEALTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28164 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875928164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055018974 | ||||||||
| FaxNumber: | 5055018974 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 884352417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754720745 | ||||||||
| FaxNumber: | 5754720746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | VEGA | ||||||||
| AuthorizedOfficialFirstName: | SUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATIONS OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5052354002 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01981331 | 05 | NM | MEDICAID |