Healthcare Provider Details

I. General information

NPI: 1295692614
Provider Name (Legal Business Name): STEPHEN KENT JUDY LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 YALE BLVD SE
ALBUQUERQUE NM
87106-4273
US

IV. Provider business mailing address

1 LOS RANCHOS RD UNIT 4
LOS LUNAS NM
87031-8967
US

V. Phone/Fax

Practice location:
  • Phone: 505-304-2812
  • Fax:
Mailing address:
  • Phone: 505-919-9681
  • Fax: 505-919-9681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2025-0947
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: