Healthcare Provider Details

I. General information

NPI: 1326589623
Provider Name (Legal Business Name): WALTER SCOTT LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SUNSET LOOP
MESCALERO NM
88340-0228
US

IV. Provider business mailing address

PO BOX 228
MESCALERO NM
88340-0228
US

V. Phone/Fax

Practice location:
  • Phone: 575-464-4432
  • Fax: 575-464-4431
Mailing address:
  • Phone: 575-464-4432
  • Fax: 575-464-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0175541
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: