Healthcare Provider Details

I. General information

NPI: 1154698553
Provider Name (Legal Business Name): MEGDA-LYN FREESTONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 CYPRESS POINT WAY NE
ALBUQUERQUE NM
87111-6411
US

IV. Provider business mailing address

609 PUFFIN ST SW
ALBUQUERQUE NM
87121-8911
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-1550
  • Fax:
Mailing address:
  • Phone: 505-385-6531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: