Basic Information
| Provider Information | |||||||||
| NPI: | 1861886632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH WEST HEALING AND CHANGE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8205 SPAIN ROAD NE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053847352 | ||||||||
| FaxNumber: | 5052747338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1424 DEBORAH ROAD SE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054158085 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | BRICKLEY | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | LPCC/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2158035261 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0146921 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.