Healthcare Provider Details

I. General information

NPI: 1922259837
Provider Name (Legal Business Name): VICKI SUE CAUCUTT LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 10/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

472 COURTHOUSE RD
LOS LUNAS NM
87031
US

IV. Provider business mailing address

2202 MENAUL BLVD NE SUITE B, C, D
ALBUQUERQUE NM
87107
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-5499
  • Fax:
Mailing address:
  • Phone: 505-888-5499
  • Fax: 505-888-5498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5212
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: