Provider Demographics
NPI:1720408487
Name:AFFECTIVE THERAPEUTIC SOLUTIONS LLC
Entity Type:Organization
Organization Name:AFFECTIVE THERAPEUTIC SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-264-1698
Mailing Address - Street 1:1005 21ST ST SE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4030
Mailing Address - Country:US
Mailing Address - Phone:505-264-1698
Mailing Address - Fax:505-359-3243
Practice Address - Street 1:1005 21ST ST SE
Practice Address - Street 2:SUITE 11
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4030
Practice Address - Country:US
Practice Address - Phone:505-264-1698
Practice Address - Fax:505-359-3243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-075021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29283396Medicaid
NMNMA102254Medicare PIN