Provider Demographics
NPI:1790301026
Name:CAPITAN THERAPY & BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:CAPITAN THERAPY & BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WUDARZEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-273-0982
Mailing Address - Street 1:PO BOX 1054
Mailing Address - Street 2:
Mailing Address - City:CAPITAN
Mailing Address - State:NM
Mailing Address - Zip Code:88316-1054
Mailing Address - Country:US
Mailing Address - Phone:505-273-0982
Mailing Address - Fax:
Practice Address - Street 1:102 EAST SMOKEY BEAR BLVD
Practice Address - Street 2:
Practice Address - City:CAPITAN
Practice Address - State:NM
Practice Address - Zip Code:88316
Practice Address - Country:US
Practice Address - Phone:505-273-0982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health