Provider Demographics
NPI:1578831780
Name:NEW MEXICO BEHAVIORAL HEALTH INSTITUTE
Entity Type:Organization
Organization Name:NEW MEXICO BEHAVIORAL HEALTH INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-454-5134
Mailing Address - Street 1:3695 HOT SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-9549
Mailing Address - Country:US
Mailing Address - Phone:505-454-5100
Mailing Address - Fax:505-454-5172
Practice Address - Street 1:700 FRIEDMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4231
Practice Address - Country:US
Practice Address - Phone:505-454-5100
Practice Address - Fax:505-454-5172
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW MEXICO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-075391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty