Provider Demographics
NPI:1972626463
Name:LABYRINTH LLC
Entity type:Organization
Organization Name:LABYRINTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:ELDEN
Authorized Official - Last Name:DETTWEILER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-603-0641
Mailing Address - Street 1:14 MELADO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-2254
Mailing Address - Country:US
Mailing Address - Phone:505-603-0641
Mailing Address - Fax:
Practice Address - Street 1:453 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-3784
Practice Address - Country:US
Practice Address - Phone:505-603-0641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12452777Medicaid
NMVNM01398OtherVALUE OPTIONS