Provider Demographics
NPI:1760173173
Name:NORTH STAR PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:NORTH STAR PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:575-770-7836
Mailing Address - Street 1:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:ARROYO SECO
Mailing Address - State:NM
Mailing Address - Zip Code:87514-0164
Mailing Address - Country:US
Mailing Address - Phone:575-770-7836
Mailing Address - Fax:
Practice Address - Street 1:208 PASEO DEL PUEBLO SUR UNIT 103
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-5931
Practice Address - Country:US
Practice Address - Phone:575-770-7836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty