Provider Demographics
NPI:1235424839
Name:HAHTATLEY, CHARLENE (BA, TLADAC)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:
Last Name:HAHTATLEY
Suffix:
Gender:F
Credentials:BA, TLADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W BROADWAY
Mailing Address - Street 2:D
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5638
Mailing Address - Country:US
Mailing Address - Phone:505-326-9157
Mailing Address - Fax:505-326-5055
Practice Address - Street 1:420 W BROADWAY
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5908
Practice Address - Country:US
Practice Address - Phone:505-326-9157
Practice Address - Fax:505-326-5055
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0067202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)