Basic Information
| Provider Information | |||||||||
| NPI: | 1093080269 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BIENESTAR FAMILY COUNSELING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1137 | ||||||||
| Address2: | |||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880081137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152035103 | ||||||||
| FaxNumber: | 5755413669 | ||||||||
| Practice Location | |||||||||
| Address1: | 4950 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880089621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152035103 | ||||||||
| FaxNumber: | 5755413669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | RIVAS | ||||||||
| AuthorizedOfficialFirstName: | MIRIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9152035103 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LPCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0128131 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.