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1524 Bishops Lodge Road Tesuque NM 87574-0449 | |
| (505) 983-6158 | |
| (505) 983-0460 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 1524 Bishops Lodge Road, Tesuque, New Mexico |
| Authorized Official Name and Position | Juan Dixon (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 5054903549 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 449 Tesuque NM 87574-0449 Ph: (505) 983-6158 | 1524 Bishops Lodge Road Tesuque NM 87574-0449 Ph: (505) 983-6158 |
| NPI Number | 1861695769 |
|---|---|
| Provider Enumeration Date | 06/07/2007 |
| Last Update Date | 07/01/2020 |
| Certification Date | 07/01/2020 |
| Medicare PECOS PAC ID | 6406272608 |
|---|---|
| Medicare Enrollment ID | O20200819000307 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1861695769 | NPI | - | NPPES |
| NM600490 | Other | NM | VALUEOPTIONSNM PROVIDER # |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Ernesto Santistevan |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1114137684 PECOS PAC ID: 4981792942 Enrollment ID: I20071109000048 |
| Provider Name | Kristin Nicole Wilson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1851747596 PECOS PAC ID: 5799077095 Enrollment ID: I20160707000164 |
| Provider Name | Terry Waters |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801316740 PECOS PAC ID: 7113286501 Enrollment ID: I20180110000921 |
| Provider Name | Richard D Gadomski |
|---|---|
| Provider Type | Practitioner - Preventive Medicine |
| Provider Identifiers | NPI Number: 1700270873 PECOS PAC ID: 2365869716 Enrollment ID: I20200831000779 |
| Provider Name | Eliza Skye |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1427677343 PECOS PAC ID: 6406266055 Enrollment ID: I20240325003804 |
| Provider Name | Margaret F Fox |
|---|---|
| Provider Type | Practitioner - Preventive Medicine |
| Provider Identifiers | NPI Number: 1003894452 PECOS PAC ID: 3779522396 Enrollment ID: I20241015002578 |
| Provider Name | Margaret E Kelley |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1992041362 PECOS PAC ID: 2264965649 Enrollment ID: I20241023002805 |
| Provider Name | Edward Davidson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1497271142 PECOS PAC ID: 1153856406 Enrollment ID: I20241122001377 |