Provider Demographics
NPI:1932777281
Name:TAOS PUEBLO BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:TAOS PUEBLO BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MESH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-770-9651
Mailing Address - Street 1:PO BOX 1846
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571
Mailing Address - Country:US
Mailing Address - Phone:575-758-6900
Mailing Address - Fax:575-751-5219
Practice Address - Street 1:1090 GOAT SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:575-758-6900
Practice Address - Fax:575-751-5219
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF TAOS -CMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM72150041Medicaid