Provider Demographics
NPI:1437554961
Name:THE COUPLE AND FAMILY THERAPY CENTER OF NEW MEXICO LLC
Entity Type:Organization
Organization Name:THE COUPLE AND FAMILY THERAPY CENTER OF NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GATELY
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-414-3883
Mailing Address - Street 1:PO BOX 10762
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87184-0762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4010 CARLISLE BLVD NE STE G
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4532
Practice Address - Country:US
Practice Address - Phone:505-414-3883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03303958005251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89522711Medicaid