Healthcare Provider Details

I. General information

NPI: 1598849564
Provider Name (Legal Business Name): EDWARD VINCENT DALY L.S.S.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87125-0445
US

IV. Provider business mailing address

1405 SAN CARLOS RD SW APT 11
ALBUQUERQUE NM
87104-1060
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-6738
  • Fax: 505-344-1862
Mailing address:
  • Phone: 505-344-6738
  • Fax: 505-344-1862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0084341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: