Provider Demographics
NPI:1043960636
Name:BLUE PHOENIX THERAPY LLC
Entity type:Organization
Organization Name:BLUE PHOENIX THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BARELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-219-1028
Mailing Address - Street 1:1740 GRANDE BLVD SE STE D-4
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1799
Mailing Address - Country:US
Mailing Address - Phone:505-219-1028
Mailing Address - Fax:
Practice Address - Street 1:1740 GRANDE BLVD SE STE D-4
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1799
Practice Address - Country:US
Practice Address - Phone:505-219-1028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01354353Medicaid