Provider Demographics
NPI:1619208584
Name:PALMISANO, NICHOLAS A (LADAC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:A
Last Name:PALMISANO
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 1:37 PLAZA LA PRENSA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-9724
Mailing Address - Country:US
Mailing Address - Phone:505-257-8766
Mailing Address - Fax:505-476-9272
Practice Address - Street 1:37 PLAZA LA PRENSA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-9724
Practice Address - Country:US
Practice Address - Phone:505-257-8766
Practice Address - Fax:505-792-8983
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCAD0161441101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39272087Medicaid