Provider Demographics
NPI:1447776695
Name:ASPEN VISTA THERAPY, LLC
Entity Type:Organization
Organization Name:ASPEN VISTA THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAFTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-577-7866
Mailing Address - Street 1:1691 GALISTEO ST STE D
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4781
Mailing Address - Country:US
Mailing Address - Phone:505-954-1921
Mailing Address - Fax:505-983-6520
Practice Address - Street 1:1691 GALISTEO ST STE D
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4781
Practice Address - Country:US
Practice Address - Phone:505-954-1921
Practice Address - Fax:505-983-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM17-00146320261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)