Provider Demographics
NPI:1164579082
Name:PB & J FAMILY SERVICES, INC.
Entity Type:Organization
Organization Name:PB & J FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC. DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MSW, LISW
Authorized Official - Phone:505-877-7060
Mailing Address - Street 1:1101 LOPEZ SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105
Mailing Address - Country:US
Mailing Address - Phone:505-877-7060
Mailing Address - Fax:505-877-7063
Practice Address - Street 1:1101 LOPEZ RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3954
Practice Address - Country:US
Practice Address - Phone:505-877-7060
Practice Address - Fax:505-877-7063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251S00000X, 261QD1600X, 261QH0100X, 261QM0801X
NM252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM600403Medicaid
NM000Q3467Medicaid