Provider Demographics
NPI:1699221366
Name:PIVOTAL TREATMENT GROUP, LLC
Entity Type:Organization
Organization Name:PIVOTAL TREATMENT GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ-BOWERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-796-2095
Mailing Address - Street 1:2549 TWIN BUTTES DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-6742
Mailing Address - Country:US
Mailing Address - Phone:505-796-2095
Mailing Address - Fax:
Practice Address - Street 1:2549 TWIN BUTTES DR NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-6742
Practice Address - Country:US
Practice Address - Phone:505-796-2095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0152101251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health