Provider Demographics
NPI:1649296252
Name:EXPRESSIONS OF LIFE
Entity type:Organization
Organization Name:EXPRESSIONS OF LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTOYA-HERRERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-831-6250
Mailing Address - Street 1:3811 ATRISCO DR NW STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4903
Mailing Address - Country:US
Mailing Address - Phone:505-831-6250
Mailing Address - Fax:505-831-6254
Practice Address - Street 1:3811 ATRISCO DR NW STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4903
Practice Address - Country:US
Practice Address - Phone:505-831-6250
Practice Address - Fax:505-831-6254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02-942112-00-8320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA0413Medicaid