Provider Demographics
NPI:1396950390
Name:SANTA FE PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:SANTA FE PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNESTO
Authorized Official - Middle Name:FELIX
Authorized Official - Last Name:SANTISTEVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-577-2607
Mailing Address - Street 1:1000 CORDOVA PL
Mailing Address - Street 2:#548
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-1725
Mailing Address - Country:US
Mailing Address - Phone:505-577-2607
Mailing Address - Fax:505-982-1096
Practice Address - Street 1:1807 2ND ST
Practice Address - Street 2:SUITE 44
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3499
Practice Address - Country:US
Practice Address - Phone:505-577-2607
Practice Address - Fax:505-982-1096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ0874Medicaid