Provider Demographics
NPI:1922499136
Name:MASADA HOUSE INC
Entity Type:Organization
Organization Name:MASADA HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS LADAC
Authorized Official - Phone:505-325-9205
Mailing Address - Street 1:610 N DUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401
Mailing Address - Country:US
Mailing Address - Phone:505-325-9205
Mailing Address - Fax:505-325-9216
Practice Address - Street 1:610 N DUSTIN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-325-9205
Practice Address - Fax:505-325-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0154441101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty