Healthcare Provider Details

I. General information

NPI: 1619129509
Provider Name (Legal Business Name): SANTANA M TITLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2008
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022-0640
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-3200
  • Fax: 505-869-4584
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0114121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: