Basic Information
Provider Information
NPI: 1790970879
EntityType: 2
ReplacementNPI:  
OrganizationName: THE FAMILY CONNECTION LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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Mailing Information
Address1: 2441 CABEZON BLVD SE
Address2:  
City: RIO RANCHO
State: NM
PostalCode: 87124
CountryCode: US
TelephoneNumber: 5057171155
FaxNumber: 5057171473
Practice Location
Address1: 2441 CABEZON BLVD SE
Address2:  
City: RIO RANCHO
State: NM
PostalCode: 87124
CountryCode: US
TelephoneNumber: 5057171155
FaxNumber: 5057171473
Other Information
ProviderEnumerationDate: 09/11/2007
LastUpdateDate: 08/28/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: DAVISON
AuthorizedOfficialFirstName: AMANDA
AuthorizedOfficialMiddleName: S
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 5057171155
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MA LMFT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251S00000XPT0088431NMN AgenciesCommunity/Behavioral Health 
251S00000X NMY AgenciesCommunity/Behavioral Health 

ID Information
IDTypeStateIssuerDescription
5023927905NM MEDICAID


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