Provider Demographics
NPI:1932313400
Name:GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Entity Type:Organization
Organization Name:GREATER SANTA ROSA COUNCIL ON ALCOHOLISM
Other - Org Name:PROFESSIONAL COUNSELING ASSOCIATES OF NEW MEXICO
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:MOYA
Authorized Official - Suffix:
Authorized Official - Credentials:LISW/LPCC
Authorized Official - Phone:505-306-6064
Mailing Address - Street 1:PO BOX 392
Mailing Address - Street 2:
Mailing Address - City:TUCUMCARI
Mailing Address - State:NM
Mailing Address - Zip Code:88401-0392
Mailing Address - Country:US
Mailing Address - Phone:505-306-6064
Mailing Address - Fax:
Practice Address - Street 1:419 S 2ND ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2859
Practice Address - Country:US
Practice Address - Phone:505-306-6064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLISW1041C0700X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM000217OtherVALUE OPTIONS
NM000A3588Medicaid