=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629948187
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEVILLE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2025
-----------------------------------------------------
Last Update Date | 11/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 MARQUETTE AVE NW STE 1200
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-503-4804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 MARQUETTE AVE NW STE 1200
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-5312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-503-4804
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | UBAH ABDI HASSAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-271-4262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------