Provider Demographics
NPI:1689214959
Name:MIND HEART AND SOUL COUNSELING LLC
Entity Type:Organization
Organization Name:MIND HEART AND SOUL COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RUSSELL FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:505-220-5809
Mailing Address - Street 1:PO BOX 15454
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-0454
Mailing Address - Country:US
Mailing Address - Phone:505-220-5809
Mailing Address - Fax:
Practice Address - Street 1:315 ALAMEDA BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2155
Practice Address - Country:US
Practice Address - Phone:505-220-5809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM56552564Medicaid