Healthcare Provider Details

I. General information

NPI: 1750687919
Provider Name (Legal Business Name): MATILDA BEGAY LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MATILDA WHITE LSAA

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PINSBAARI DRIVE
ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 328
ACOMA NM
87034
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-6661
  • Fax: 505-552-6426
Mailing address:
  • Phone: 505-552-6661
  • Fax: 505-552-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0187771
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: