Healthcare Provider Details

I. General information

NPI: 1194565481
Provider Name (Legal Business Name): LOU PACKER LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 LEAD AVE SE
ALBUQUERQUE NM
87106-4007
US

IV. Provider business mailing address

2824 WASHINGTON ST NE
ALBUQUERQUE NM
87110-2930
US

V. Phone/Fax

Practice location:
  • Phone: 505-895-0147
  • Fax: 505-441-2954
Mailing address:
  • Phone: 505-492-8440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: