MEDICARE: MATT CHARLES LADISH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0387	NM

General Provider Information

NPI Number	:	1831675602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATT CHARLES LADISH

Provider Business Mailing Address
First Line	:	4032 CALLE DE ESTRELLAS
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7639
Country	:	US
Telephone Number	:	575-636-7881
Fax Number	:

Provider Business Practice Location Address
First Line	:	4032 CALLE DE ESTRELLAS
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-7639
Country	:	US
Telephone Number	:	575-636-7881
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	07/16/2018

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Directions to “ MATT CHARLES LADISH ” Practice Location

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