Provider Demographics
NPI:1295389054
Name:ANDRADA, REBECCA ROSALEE (LSAA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ROSALEE
Last Name:ANDRADA
Suffix:
Gender:F
Credentials:LSAA
Other - Prefix:
Other - First Name:ROSALEE
Other - Middle Name:
Other - Last Name:ANDRADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSAA
Mailing Address - Street 1:129 REDWOOD PL SW
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1481
Mailing Address - Country:US
Mailing Address - Phone:505-435-4419
Mailing Address - Fax:
Practice Address - Street 1:630 HAINES AVE NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1226
Practice Address - Country:US
Practice Address - Phone:505-268-5611
Practice Address - Fax:505-268-5736
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0188341101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty