Healthcare Provider Details

I. General information

NPI: 1710647789
Provider Name (Legal Business Name): LAURA ADDISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 03/17/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7689B OLD SANTA FE TRL
SANTA FE NM
87505-9348
US

IV. Provider business mailing address

7689B OLD SANTA FE TRL
SANTA FE NM
87505-9348
US

V. Phone/Fax

Practice location:
  • Phone: 404-290-4682
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: