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General NPI Number Information
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NPI Number | 1922499136
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Entity Type | Organization
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Legal Business Name | MASADA HOUSE INC
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 610 N DUSTIN AVE
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City | FARMINGTON
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State | NM
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Zip | 87401
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Country | US
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Telephone | 505-325-9205
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Fax | 505-325-9216
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Provider Business Mailing Address
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Address Line | 610 N DUSTIN AVE
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City | FARMINGTON
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State | NM
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Zip | 87401
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Country | US
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Telephone | 505-325-9205
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Fax | 505-325-9216
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | SHAWNA B RILEY
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Credential | BS LADAC
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Telephone | 505-325-9205
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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 | 0154441
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License Number State | NM
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