Provider Demographics
NPI:1881911188
Name:THE EXODUS 14/20 PSYCHOSOCIAL REHAB CENTER
Entity type:Organization
Organization Name:THE EXODUS 14/20 PSYCHOSOCIAL REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOSOCIAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LA TONYA
Authorized Official - Middle Name:DELILAH
Authorized Official - Last Name:WESTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:BS/P CPRP
Authorized Official - Phone:505-438-2000
Mailing Address - Street 1:6921 AIRPORT RD
Mailing Address - Street 2:#1209
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-1838
Mailing Address - Country:US
Mailing Address - Phone:505-438-2000
Mailing Address - Fax:
Practice Address - Street 1:919 RIVERSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-438-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty