Healthcare Provider Details

I. General information

NPI: 1104965243
Provider Name (Legal Business Name): JEFFREY GEORGE STADLER MA LMHP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 12/05/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CENTRAL PARK SQ STE 204
LOS ALAMOS NM
87544-4005
US

IV. Provider business mailing address

2423 CLUB RD
LOS ALAMOS NM
87544-1501
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-5719
  • Fax:
Mailing address:
  • Phone: 575-779-5719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2723
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: