Healthcare Provider Details

I. General information

NPI: 1114165594
Provider Name (Legal Business Name): HOLLY RAE LADAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 01/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SIPAPU ROAD
TAOS NM
87571
US

IV. Provider business mailing address

750 GUSDORF # 308
TAOS NM
87571
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-5857
  • Fax: 575-758-2832
Mailing address:
  • Phone: 575-758-9666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0065382
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: