Provider Demographics
NPI:1023413788
Name:TAHLIA RAINBOLT, PHD, LLC
Entity type:Organization
Organization Name:TAHLIA RAINBOLT, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAHLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAINBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-989-3340
Mailing Address - Street 1:460 SAINT MICHAELS DR
Mailing Address - Street 2:SUITE 505
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:460 SAINT MICHAELS DR
Practice Address - Street 2:SUITE 505
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7619
Practice Address - Country:US
Practice Address - Phone:505-989-3340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1308251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37686232Medicaid