Healthcare Provider Details

I. General information

NPI: 1386879187
Provider Name (Legal Business Name): ELLYN F THOMPSON LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 CIELO AZUL RD
LOS LUNAS NM
87031-7240
US

IV. Provider business mailing address

79 CIELO AZUL RD
LOS LUNAS NM
87031-7240
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-5439
  • Fax:
Mailing address:
  • Phone: 505-866-5439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0088751
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: