Provider Demographics
NPI:1083735997
Name:SANCHEZ, MARK (LADAC,LCDC,ICADC,CAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SANCHEZ
Suffix:
Gender:M
Credentials:LADAC,LCDC,ICADC,CAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2707
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-2707
Mailing Address - Country:US
Mailing Address - Phone:505-368-4825
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY STE D
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-325-0238
Practice Address - Fax:505-327-7247
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0084741101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)