Healthcare Provider Details

I. General information

NPI: 1609083468
Provider Name (Legal Business Name): WANDA MAE WESTBROOK NMLADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 N, PINON STREET
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 1830
SHIPROCK NM
87420-1830
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1069
  • Fax: 505-368-1055
Mailing address:
  • Phone: 505-368-1050
  • Fax: 505-368-1055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4046
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: