Provider Demographics
NPI:1497537658
Name:SELF-DISCOVERY RECOVERY LLC
Entity Type:Organization
Organization Name:SELF-DISCOVERY RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERASIMOS
Authorized Official - Middle Name:DEMOSTHENIS
Authorized Official - Last Name:KLONIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-603-8633
Mailing Address - Street 1:2980 CLEAR SKY ST SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6453
Mailing Address - Country:US
Mailing Address - Phone:505-603-8633
Mailing Address - Fax:
Practice Address - Street 1:1052 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7436
Practice Address - Country:US
Practice Address - Phone:505-603-8633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2024-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19024576Medicaid