Healthcare Provider Details

I. General information

NPI: 1457065492
Provider Name (Legal Business Name): DAVID EDWARD SALAS M.A., M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 A PLACITAS
EL RITO NM
87530
US

IV. Provider business mailing address

PO BOX 418
OJO CALIENTE NM
87549-0418
US

V. Phone/Fax

Practice location:
  • Phone: 505-652-8082
  • Fax:
Mailing address:
  • Phone: 505-652-8082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCTB-2022-0962
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: