Healthcare Provider Details

I. General information

NPI: 1376735464
Provider Name (Legal Business Name): JOSEPH E. SWEENEY LPC/LADAC/SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103A SAGAR DRIVE
VANDERWAGEN NM
87326
US

IV. Provider business mailing address

PO BOX 190
VANDERWAGEN NM
87326-0190
US

V. Phone/Fax

Practice location:
  • Phone: 505-778-5151
  • Fax: 505-772-5151
Mailing address:
  • Phone: 505-778-5151
  • Fax: 505-778-5151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-0104081
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0089971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: