Healthcare Provider Details

I. General information

NPI: 1639394687
Provider Name (Legal Business Name): BOBBI JO DAGGETT CADAC #1034
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 05/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 HAINES AVE. NE
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

4623 LA VIDA NUEVA DEL NORTE SW
ALBUQUERQUE NM
87105-2660
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5611
  • Fax: 505-268-5736
Mailing address:
  • Phone: 505-315-3789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1034
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: