Healthcare Provider Details

I. General information

NPI: 1952027385
Provider Name (Legal Business Name): ALEXANDRA BRIGHT LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

IV. Provider business mailing address

5901 ZUNI RD SE
ALBUQUERQUE NM
87108-3073
US

V. Phone/Fax

Practice location:
  • Phone: 505-468-1579
  • Fax:
Mailing address:
  • Phone: 505-468-1579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0197291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: