Provider Demographics
NPI:1497116206
Name:CHARLEY, EMERSON (LSAA)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:
Last Name:CHARLEY
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:505-471-4985
Mailing Address - Fax:
Practice Address - Street 1:2105 HASLER VALLEY RD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-8730
Practice Address - Country:US
Practice Address - Phone:505-471-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0209321101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)