MEDICARE: PAUL CONDES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	M-07952	NM

General Provider Information

NPI Number	:	1053622845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL CONDES

Provider Business Mailing Address
First Line	:	9201 REBA AVE SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-9001
Country	:	US
Telephone Number	:	505-550-3687
Fax Number	:

Provider Business Practice Location Address
First Line	:	9201 REBA AVE SW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-9001
Country	:	US
Telephone Number	:	505-550-3687
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2010
Last Update Date	:	11/20/2012

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