Organization
EARTH SPIRIT AWAKENINGS LLC
Active
Other names
Mesa Vista Wellness
Organization subpart
No
Provider details
NPI number
Authorized official
TOD L DICECCO MA, LPCC (EXECUTIVE DIRECTOR/OWNER)
(505) 490-1984
Entity
Organization
Contact information
Practice address
4001 OFFICE COURT DR STE 102, SANTA FE, NM 87507-4903
(505) 983-8225
Mailing address
4001 OFFICE COURT DR, SUITE 102, SANTA FE, NM 87507-4929
(505) 983-8225
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
0119891
NM
251S00000X
Community/Behavioral Health Agency
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
81024371
—
NM
Enumeration date
02/25/2009
Last updated
02/10/2022
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