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General NPI Number Information
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NPI Number | 1801625793
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Entity Type | Individual
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Provider Name | EDGAR AJANY ALONSO BA
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Gender | Male
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Dates
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Enumeration Date | 07/29/2024
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Last Update Date | 07/29/2024
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Provider Practice Location Address
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Address Line | 400 GOLD AVE SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87102-3283
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Country | US
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Telephone | 505-224-9124
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Fax |
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Provider Business Mailing Address
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Address Line | 13232 SILVER PEAK PL NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-8261
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Country | US
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Telephone | 757-272-4149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CTB-2024-0549
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License Number State | NM
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