Healthcare Provider Details

I. General information

NPI: 1124108055
Provider Name (Legal Business Name): BOBBI JEAN FRADY MC,LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 MORRIS RD SE
LOS LUNAS NM
87031-5242
US

IV. Provider business mailing address

2551 COORS BLVD NW
ALBUQUERQUE NM
87120-1213
US

V. Phone/Fax

Practice location:
  • Phone: 505-866-2318
  • Fax: 505-869-4881
Mailing address:
  • Phone:
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3699
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3699
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: