Provider Demographics
NPI:1477276046
Name:NEW MEXICO DREAM CENTER OF ALBUQUERQUE
Entity Type:Organization
Organization Name:NEW MEXICO DREAM CENTER OF ALBUQUERQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:REPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-217-5060
Mailing Address - Street 1:126 GENERAL CHENNAULT ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2515
Mailing Address - Country:US
Mailing Address - Phone:505-900-3833
Mailing Address - Fax:505-212-6422
Practice Address - Street 1:126 GENERAL CHENNAULT ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-2515
Practice Address - Country:US
Practice Address - Phone:505-900-3833
Practice Address - Fax:505-212-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1023164498Medicaid