Healthcare Provider Details

I. General information

NPI: 1548861503
Provider Name (Legal Business Name): GARY ALAN RICHARD LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 11/05/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2957 MAIN ST. RT. 302
BETHLEHEM NH
03574
US

IV. Provider business mailing address

2957 MAIN ST. RT. 302
BETHLEHEM NH
03574
US

V. Phone/Fax

Practice location:
  • Phone: 606-707-5076
  • Fax: 603-869-2355
Mailing address:
  • Phone: 606-707-5076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1130
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: