Provider Demographics
NPI:1891056909
Name:FOUR CORNERS MENTAL AND BEHAVIORAL HEALTH PC
Entity Type:Organization
Organization Name:FOUR CORNERS MENTAL AND BEHAVIORAL HEALTH PC
Other - Org Name:FCMBH-PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:SOLIS
Authorized Official - Last Name:BACA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-200-9855
Mailing Address - Street 1:PO BOX 95602
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199
Mailing Address - Country:US
Mailing Address - Phone:505-504-5505
Mailing Address - Fax:505-214-5614
Practice Address - Street 1:1003 LUNA CIR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1973
Practice Address - Country:US
Practice Address - Phone:505-504-5505
Practice Address - Fax:505-214-5614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37776825Medicaid
NM37776825Medicaid