Provider Demographics
NPI:1669622189
Name:FAMILIES TOGETHER/SELF REALIZATION THERAPY
Entity type:Organization
Organization Name:FAMILIES TOGETHER/SELF REALIZATION THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ACKLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:505-332-8549
Mailing Address - Street 1:4938 ARROYO CHAMISA RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3716
Mailing Address - Country:US
Mailing Address - Phone:505-332-8549
Mailing Address - Fax:505-332-8549
Practice Address - Street 1:9004 MENAUL BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2259
Practice Address - Country:US
Practice Address - Phone:505-440-6009
Practice Address - Fax:505-332-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI058221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM100451Medicaid