Healthcare Provider Details

I. General information

NPI: 1992498794
Provider Name (Legal Business Name): HARLEY LAWSON YEAROUT LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 SAN PEDRO DR NE BLDG D1
ALBUQUERQUE NM
87110-8905
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE STE V
ALBUQUERQUE NM
87111-2470
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-1717
  • Fax: 505-213-0041
Mailing address:
  • Phone: 505-507-7984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2023-0076
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: