Provider Demographics
NPI:1467218784
Name:SEALIGHT WELLNESS LLC
Entity Type:Organization
Organization Name:SEALIGHT WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-519-1502
Mailing Address - Street 1:PO BOX 40742
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87196-0742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 MONTGOMERY BLVD NE STE B203
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1202
Practice Address - Country:US
Practice Address - Phone:505-519-1502
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-23
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty