Provider Demographics
NPI:1801541875
Name:ACTIVATE BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:ACTIVATE BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MYSTRI
Authorized Official - Middle Name:
Authorized Official - Last Name:HIPSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-635-3087
Mailing Address - Street 1:2501 E 20TH ST STE 19
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 E 20TH ST STE 19
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-4447
Practice Address - Country:US
Practice Address - Phone:505-634-9289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health