Healthcare Provider Details

I. General information

NPI: 1699229559
Provider Name (Legal Business Name): LOUISE BLAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 ROMA AVE NE
ALBUQUERQUE NM
87108-2334
US

IV. Provider business mailing address

8000 ROMA AVE NE
ALBUQUERQUE NM
87108-2334
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-4823
  • Fax:
Mailing address:
  • Phone: 505-884-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0182811
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: