Healthcare Provider Details

I. General information

NPI: 1972769875
Provider Name (Legal Business Name): SUZANNAH MIRIAM GOULD LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 NORTH PINION STREET
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 1830
SHIPROCK NM
87420-1830
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1050
  • Fax: 505-368-1437
Mailing address:
  • Phone: 505-368-1050
  • Fax: 505-368-1437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4441
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: