Provider Demographics
NPI:1558654483
Name:AMISTAD FAMILY SERVICES INC
Entity Type:Organization
Organization Name:AMISTAD FAMILY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD OF DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DERYL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:575-642-7557
Mailing Address - Street 1:3100 OAK ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3425
Mailing Address - Country:US
Mailing Address - Phone:575-523-2288
Mailing Address - Fax:
Practice Address - Street 1:3100 OAK ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:575-523-2288
Practice Address - Fax:575-523-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-25
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
NMI-06859251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty