Provider Demographics
NPI:1376822296
Name:EXODUS PEER TO PEER RECOVERY CENTER
Entity type:Organization
Organization Name:EXODUS PEER TO PEER RECOVERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LA TONYA
Authorized Official - Middle Name:DELILAH
Authorized Official - Last Name:WESTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:CPSW, PASTOR, FC
Authorized Official - Phone:505-819-9740
Mailing Address - Street 1:419 E. MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402
Mailing Address - Country:US
Mailing Address - Phone:505-819-9740
Mailing Address - Fax:
Practice Address - Street 1:419 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2707
Practice Address - Country:US
Practice Address - Phone:505-819-9740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:B'SORAH HOUSING AND SOCIAL SERVICE AGENCY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YP1600X, 133NN1002X, 171M00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty