Provider Demographics
NPI:1801186069
Name:RESILIENCE INTEGRATIVE SERVICES LLC
Entity Type:Organization
Organization Name:RESILIENCE INTEGRATIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-315-7397
Mailing Address - Street 1:5212 PARK HEIGHTS RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 VIRGINIA ST NE
Practice Address - Street 2:STE. 201
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1093
Practice Address - Country:US
Practice Address - Phone:505-977-3112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0983251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health