Provider Demographics
NPI:1427567486
Name:TRAUMA TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:TRAUMA TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-289-1042
Mailing Address - Street 1:1316 JACKIE RD SE STE 900
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6612
Mailing Address - Country:US
Mailing Address - Phone:505-289-1042
Mailing Address - Fax:
Practice Address - Street 1:1316 JACKIE RD SE STE 900
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6612
Practice Address - Country:US
Practice Address - Phone:505-289-1042
Practice Address - Fax:505-466-5895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 225X00000X, 251S00000X
NM0185071261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health