Healthcare Provider Details

I. General information

NPI: 1578285110
Provider Name (Legal Business Name): NICHOLAS AMIRANTE LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 BARBARA LOOP SE
RIO RANCHO NM
87124-1000
US

IV. Provider business mailing address

1804 GALLINAS RD NE
RIO RANCHO NM
87144-2512
US

V. Phone/Fax

Practice location:
  • Phone: 505-702-8547
  • Fax:
Mailing address:
  • Phone: 505-417-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCBT-2022-0316
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: