Provider Demographics
NPI:1245417104
Name:PUEBLO OF ISLETA BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:PUEBLO OF ISLETA BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARTA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-869-4863
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0000
Mailing Address - Country:US
Mailing Address - Phone:505-869-4863
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH ST
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022-0000
Practice Address - Country:US
Practice Address - Phone:505-869-4863
Practice Address - Fax:505-869-4881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF ISLETA HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-23
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3803775Medicaid