Healthcare Provider Details

I. General information

NPI: 1285873745
Provider Name (Legal Business Name): KIMBERLY MICHELLE JORDAN LADAC, LMFT, CPRP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2009
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 NEW YORK AVE
ALAMOGORDO NM
88310-6727
US

IV. Provider business mailing address

1215 NEW YORK AVE
ALAMOGORDO NM
88310-6727
US

V. Phone/Fax

Practice location:
  • Phone: 575-649-8518
  • Fax:
Mailing address:
  • Phone: 575-649-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number171007
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number171007
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-J0811051803
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number014701
License Number StateNM
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0176661
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: