Provider Demographics
NPI:1376035873
Name:WHITE HORSE STUDIO, LLC
Entity Type:Organization
Organization Name:WHITE HORSE STUDIO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALLING
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-202-0750
Mailing Address - Street 1:135 WHITTINGTON PL
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-9270
Mailing Address - Country:US
Mailing Address - Phone:915-588-7290
Mailing Address - Fax:575-613-7243
Practice Address - Street 1:2410 S ESPINA ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5612
Practice Address - Country:US
Practice Address - Phone:915-588-7290
Practice Address - Fax:575-613-7243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-05502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54886368Medicaid