Provider Demographics
NPI:1629009899
Name:SU VIDA
Entity Type:Organization
Organization Name:SU VIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-954-8777
Mailing Address - Street 1:1601A SAINT MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7614
Mailing Address - Country:US
Mailing Address - Phone:505-954-8777
Mailing Address - Fax:505-954-8793
Practice Address - Street 1:1601A SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7614
Practice Address - Country:US
Practice Address - Phone:505-954-8777
Practice Address - Fax:505-954-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM78558Medicaid
NMNM600536OtherVALUE OPTIONS