Healthcare Provider Details

I. General information

NPI: 1891876769
Provider Name (Legal Business Name): ABDOLHOSSEIN ENTEZARI PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 JOURNAL CENTER NE
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

PO BOX 27829
ALBUQUERQUE NM
87125
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-3212
  • Fax: 505-262-3381
Mailing address:
  • Phone: 505-262-7026
  • Fax: 505-727-9276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number468
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: