Provider Demographics
NPI:1245574136
Name:TARAZON, MELISSA ANN (LADAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:TARAZON
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W APACHE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-3886
Mailing Address - Country:US
Mailing Address - Phone:505-258-2763
Mailing Address - Fax:505-675-2803
Practice Address - Street 1:1200 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3886
Practice Address - Country:US
Practice Address - Phone:505-258-2763
Practice Address - Fax:505-675-2803
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0170431101YA0400X
NM0144081101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1124735485OtherNPI