Basic Information
Provider Information
NPI: 1891125183
EntityType: 2
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OrganizationName: ELEMENTAL HEALTH AND WELLNESS CENTER LLC
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Mailing Information
Address1: 4425 JUAN TABO BLVD NE STE 112
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871112684
CountryCode: US
TelephoneNumber: 5055036800
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Practice Location
Address1: 4425 JUAN TABO BLVD NE STE 112
Address2:  
City: ALBUQUERQUE
State: NM
PostalCode: 871112684
CountryCode: US
TelephoneNumber: 5055036800
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/22/2013
LastUpdateDate: 12/08/2021
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AuthorizedOfficialLastName: CANNON
AuthorizedOfficialFirstName: ANNE
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AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 5055036800
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IsOrganizationSubpart: N
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NPICertificationDate: 11/15/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800X0112181NMN193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorMental Health
363LP0808XCNP-02033NMN193200000X MULTI-SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsych/Mental Health
106H00000X0084711NMY193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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