Healthcare Provider Details

I. General information

NPI: 1568878585
Provider Name (Legal Business Name): RON ESTRADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1025 HERMOSA DR SE
ALBUQUERQUE NM
87108-4312
US

IV. Provider business mailing address

5324 ALVARADO PL NE
ALBUQUERQUE NM
87110-5108
US

V. Phone/Fax

Practice location:
  • Phone: 505-237-0061
  • Fax:
Mailing address:
  • Phone: 505-715-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0167481
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: