Provider Demographics
NPI:1104040088
Name:GIDDINGS, MICHAEL WAYNE (LADAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:GIDDINGS
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 CALLE DON DEMETRIO NE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-9360
Mailing Address - Country:US
Mailing Address - Phone:505-865-6748
Mailing Address - Fax:
Practice Address - Street 1:1528 FIVE POINTS RD SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-3014
Practice Address - Country:US
Practice Address - Phone:505-242-6919
Practice Address - Fax:505-242-6929
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM005486101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)