Provider Demographics
NPI:1710296496
Name:INDEPENDENT LIVING THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:INDEPENDENT LIVING THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:IVYROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:505-350-3069
Mailing Address - Street 1:12105 DAN PATCH RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-2196
Mailing Address - Country:US
Mailing Address - Phone:505-350-3069
Mailing Address - Fax:505-508-2305
Practice Address - Street 1:12105 DAN PATCH RD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-2196
Practice Address - Country:US
Practice Address - Phone:505-350-3069
Practice Address - Fax:505-508-2305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93985312Medicaid