Healthcare Provider Details

I. General information

NPI: 1104159060
Provider Name (Legal Business Name): CHANDRA S. GORDON LADAC; LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 BONITA ST
GRANTS NM
87020-2103
US

IV. Provider business mailing address

PO BOX 3348
MILAN NM
87021-3348
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2273
  • Fax: 505-287-2276
Mailing address:
  • Phone: 505-240-0823
  • Fax: 505-240-0823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0137551
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number14967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: