1508007261 NPI number — TRUE SELF LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508007261 NPI number — TRUE SELF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUE SELF LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TRUE SELF COUNSELING
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508007261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 LOUISIANA BLVD. NE
Provider Second Line Business Mailing Address:
SUITE J-1
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87110-3532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-639-5772
Provider Business Mailing Address Fax Number:
505-639-5772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 LOUISIANA BLVD. NE
Provider Second Line Business Practice Location Address:
SUITE J-1
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87110-3532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-639-5772
Provider Business Practice Location Address Fax Number:
505-639-5780
Provider Enumeration Date:
03/10/2009

Additional Information

Authorized Official

Authorized Official Last Name:
THORNBERRY
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
CEO / OWNER / CLINICIAN
Authorized Official Telephone Number:
505-379-3703

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I06618 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 45104336 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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