Provider Demographics
NPI:1972367290
Name:TELEMENTAL HEALTH LINK LLC
Entity Type:Organization
Organization Name:TELEMENTAL HEALTH LINK LLC
Other - Org Name:TELEMENTAL HEALTH LINK -NM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DERIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:208-775-7418
Mailing Address - Street 1:4055 E BLUEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8261
Mailing Address - Country:US
Mailing Address - Phone:208-775-7418
Mailing Address - Fax:208-674-5008
Practice Address - Street 1:5700 HARPER DR NE STE 210-4
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3573
Practice Address - Country:US
Practice Address - Phone:208-775-7418
Practice Address - Fax:208-768-4500
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TELEMENTAL HEALTH LINK LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty