Healthcare Provider Details

I. General information

NPI: 1376450452
Provider Name (Legal Business Name): SHANA MARIA ACOSTA LSAA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

IV. Provider business mailing address

13139 CENTRAL AVE NE
ALBUQUERQUE NM
87123-3031
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4140
  • Fax:
Mailing address:
  • Phone: 505-865-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2026-0738
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: