Healthcare Provider Details

I. General information

NPI: 1588220826
Provider Name (Legal Business Name): BEVERLY NICOLE APODACA MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6313 BARNHART ST NE
ALBUQUERQUE NM
87109-3510
US

IV. Provider business mailing address

6313 BARNHART ST NE
ALBUQUERQUE NM
87109-3510
US

V. Phone/Fax

Practice location:
  • Phone: 505-715-8031
  • Fax:
Mailing address:
  • Phone: 505-715-8031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT3696
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT3696
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: