Healthcare Provider Details

I. General information

NPI: 1912379876
Provider Name (Legal Business Name): JUSTIN DAVID LAIRD PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 YALE BLVD SE
ALBUQUERQUE NM
87106-4383
US

IV. Provider business mailing address

2600 YALE BLVD SE
ALBUQUERQUE NM
87106-4383
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-7999
  • Fax: 505-243-0366
Mailing address:
  • Phone: 505-994-7999
  • Fax: 505-243-0366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number64187
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0163261
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN-71867
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: