Healthcare Provider Details

I. General information

NPI: 1922401165
Provider Name (Legal Business Name): STETSON LEA BERG LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2479
  • Fax: 505-272-9843
Mailing address:
  • Phone: 505-272-2479
  • Fax: 505-272-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0164591
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: