Healthcare Provider Details

I. General information

NPI: 1528375011
Provider Name (Legal Business Name): MICHAEL MAESTAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 03/22/2017
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

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2800
  • Fax: 505-272-8692
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1998
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: