Healthcare Provider Details

I. General information

NPI: 1619208584
Provider Name (Legal Business Name): NICHOLAS A PALMISANO LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 PLAZA LA PRENSA
SANTA FE NM
87507-9724
US

IV. Provider business mailing address

37 PLAZA LA PRENSA
SANTA FE NM
87507-9724
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-8766
  • Fax: 505-792-8983
Mailing address:
  • Phone: 505-257-8766
  • Fax: 505-476-9272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAD0161441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: