Provider Demographics
NPI:1316325061
Name:SERENITY WELLNESS CENTER OF SANTA FE, LLC
Entity type:Organization
Organization Name:SERENITY WELLNESS CENTER OF SANTA FE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SHELBOURN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPAT
Authorized Official - Phone:505-690-3134
Mailing Address - Street 1:1000 CORDOVA PLACE #411
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-690-3134
Mailing Address - Fax:505-216-2616
Practice Address - Street 1:343 E PALACE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501
Practice Address - Country:US
Practice Address - Phone:505-690-3134
Practice Address - Fax:505-216-2616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0094521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty