Healthcare Provider Details

I. General information

NPI: 1235545302
Provider Name (Legal Business Name): ORLINDA WILLIAMS LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MAIN STREET
SUPAI AZ
86435-0129
US

IV. Provider business mailing address

PO BOX 4391
GALLUP NM
87305-4391
US

V. Phone/Fax

Practice location:
  • Phone: 928-448-2641
  • Fax: 928-448-2312
Mailing address:
  • Phone: 928-514-4715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4004
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: