Basic Information
| Provider Information | |||||||||
| NPI: | 1447776695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASPEN VISTA THERAPY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1691 GALISTEO ST STE D | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059541921 | ||||||||
| FaxNumber: | 5059836520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1691 GALISTEO ST STE D | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059541921 | ||||||||
| FaxNumber: | 5059836520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | SHAFTER | ||||||||
| AuthorizedOfficialFirstName: | LAUREL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
| AuthorizedOfficialTelephone: | 5055777866 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 17-00146320 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.