Provider Demographics
NPI:1811433212
Name:COPPER CANYON WELLNESS, LLC
Entity type:Organization
Organization Name:COPPER CANYON WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-660-2654
Mailing Address - Street 1:1350 CENTRAL AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-3244
Mailing Address - Country:US
Mailing Address - Phone:505-660-2654
Mailing Address - Fax:
Practice Address - Street 1:1350 CENTRAL AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3244
Practice Address - Country:US
Practice Address - Phone:505-660-2654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM C41311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81130210Medicaid