Provider Demographics
NPI:1376232934
Name:INTEGRATE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:INTEGRATE WELLNESS CENTER LLC
Other - Org Name:INTEGRATE WELLNESS COUNSELING LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DIESEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-600-2314
Mailing Address - Street 1:PO BOX 36072
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87176-6072
Mailing Address - Country:US
Mailing Address - Phone:505-600-2314
Mailing Address - Fax:
Practice Address - Street 1:120 ALISO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2693
Practice Address - Country:US
Practice Address - Phone:505-600-2314
Practice Address - Fax:866-635-1177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty