Provider Demographics
NPI:1689148033
Name:CHANGE OF HEART BEHAVIOR SERVICES LLC
Entity Type:Organization
Organization Name:CHANGE OF HEART BEHAVIOR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMERO
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMSW
Authorized Official - Phone:575-635-3675
Mailing Address - Street 1:1776 VISTA MONTANA RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-6264
Mailing Address - Country:US
Mailing Address - Phone:575-635-3675
Mailing Address - Fax:575-541-9082
Practice Address - Street 1:1776 VISTA MONTANA RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-6264
Practice Address - Country:US
Practice Address - Phone:575-635-3675
Practice Address - Fax:575-541-9082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health