Provider Demographics
NPI:1831675602
Name:LADISH, MATT CHARLES
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:CHARLES
Last Name:LADISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 CALLE DE ESTRELLAS
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-7639
Mailing Address - Country:US
Mailing Address - Phone:575-636-7881
Mailing Address - Fax:
Practice Address - Street 1:4032 CALLE DE ESTRELLAS
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7639
Practice Address - Country:US
Practice Address - Phone:575-636-7881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0387101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional