Provider Demographics
NPI:1669978391
Name:EDOE LLC
Entity type:Organization
Organization Name:EDOE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:SIBLEY
Authorized Official - Last Name:DOERWALD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-473-6191
Mailing Address - Street 1:7430 OLD SANTA FE TRL
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4574
Mailing Address - Country:US
Mailing Address - Phone:505-473-6191
Mailing Address - Fax:505-983-0833
Practice Address - Street 1:518 OLD SANTA FE TRL STE 1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-0398
Practice Address - Country:US
Practice Address - Phone:505-473-6191
Practice Address - Fax:505-819-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-09941261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2837987OtherSCC#