Provider Demographics
NPI:1619536141
Name:CHILD COUNSELING CENTER AND PLAY THERAPY INSTITUTE OF NEW MEXICO
Entity type:Organization
Organization Name:CHILD COUNSELING CENTER AND PLAY THERAPY INSTITUTE OF NEW MEXICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIENVENU
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPCC
Authorized Official - Phone:505-316-1182
Mailing Address - Street 1:534 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1324
Mailing Address - Country:US
Mailing Address - Phone:505-316-1182
Mailing Address - Fax:
Practice Address - Street 1:1400 MACLOVIA ST STE 1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3253
Practice Address - Country:US
Practice Address - Phone:505-772-0459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-09
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32055072Medicaid