Healthcare Provider Details

I. General information

NPI: 1164757134
Provider Name (Legal Business Name): REBECCA HATHAWAY ALLEN LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2009
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 ISLETA BLVD SW
ALBUQUERQUE NM
87105-6658
US

IV. Provider business mailing address

6000 ISLETA BLVD SW
ALBUQUERQUE NM
87105-6658
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-2761
  • Fax: 505-873-2819
Mailing address:
  • Phone: 505-873-2761
  • Fax: 505-873-2819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0074461
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: