Healthcare Provider Details

I. General information

NPI: 1972641884
Provider Name (Legal Business Name): EMILY LOUISE EADS MS OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 BROADBENT PKWY NE STE J
ALBUQUERQUE NM
87107-1600
US

IV. Provider business mailing address

PO BOX 70103
ALBUQUERQUE NM
87197-0103
US

V. Phone/Fax

Practice location:
  • Phone: 505-341-2020
  • Fax:
Mailing address:
  • Phone: 505-514-5857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2184
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: