Provider Demographics
NPI:1306026075
Name:FAMILY TIME
Entity Type:Organization
Organization Name:FAMILY TIME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:505-486-9942
Mailing Address - Street 1:19 ROAD 3953
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7990
Mailing Address - Country:US
Mailing Address - Phone:505-486-9942
Mailing Address - Fax:
Practice Address - Street 1:19 ROAD 3953
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-7990
Practice Address - Country:US
Practice Address - Phone:505-486-9942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-06619251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health