Provider Demographics
NPI:1861163271
Name:OPEN ACCESS VIDEO COUNSELING LLC
Entity type:Organization
Organization Name:OPEN ACCESS VIDEO COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DERYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-301-3408
Mailing Address - Street 1:3005 S SAINT FRANCIS DR STE 1D
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7004
Mailing Address - Country:US
Mailing Address - Phone:505-301-3408
Mailing Address - Fax:866-593-5859
Practice Address - Street 1:2074 GALISTEO ST STE B4
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2157
Practice Address - Country:US
Practice Address - Phone:505-301-3408
Practice Address - Fax:866-593-5859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-24
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty