Basic Information
| Provider Information | |||||||||
| NPI: | 1811187289 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST FAMILY GUIDANCE CENTER & INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 SAN MATEO BLVD NE | ||||||||
| Address2: | STE. S-14 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871104058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058301871 | ||||||||
| FaxNumber: | 5058300040 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 SAN MATEO BLVD NE | ||||||||
| Address2: | STE. S-14 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871104058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058301871 | ||||||||
| FaxNumber: | 5058300040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 07/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOTHERAPIST/CHIEF CLINICAL DIR. | ||||||||
| AuthorizedOfficialTelephone: | 5058301871 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103TC1900X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 1041C0700X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 1243 | NM | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | 1243 | NM | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1243 | 01 | NM | COUNSELING | OTHER |