Healthcare Provider Details

I. General information

NPI: 1164274916
Provider Name (Legal Business Name): JAMES ALAN VANDERLAAN LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N GRANT ST STE A
SILVER CITY NM
88061-5134
US

IV. Provider business mailing address

1311 N GRANT ST STE A
SILVER CITY NM
88061-5134
US

V. Phone/Fax

Practice location:
  • Phone: 575-388-1447
  • Fax:
Mailing address:
  • Phone: 575-388-1447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0071
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: