MEDICARE: VICTORIA MILDREN LSAA

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	101YA0400X	Addiction (Substance Use Disorder) Counselor		NM

General Provider Information

NPI Number	:	1225425481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA MILDREN LSAA

Provider Business Mailing Address
First Line	:	9038 PORT RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-1967
Country	:	US
Telephone Number	:	505-818-1472
Fax Number	:

Provider Business Practice Location Address
First Line	:	9038 PORT RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87121-1967
Country	:	US
Telephone Number	:	505-818-1472
Fax Number	:

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

Provider Enumeration Date	:	04/24/2015
Last Update Date	:	04/24/2015

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Directions to “ VICTORIA MILDREN LSAA” Practice Location

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