Provider Demographics
NPI:1124251087
Name:FAULKNER, VICTOR A (LADAC)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:A
Last Name:FAULKNER
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 1:9201 MONTGOMERY BLVD NE STE V
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2470
Mailing Address - Country:US
Mailing Address - Phone:505-320-0576
Mailing Address - Fax:
Practice Address - Street 1:3939 SAN PEDRO DR NE BLDG D1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-8905
Practice Address - Country:US
Practice Address - Phone:505-440-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4397101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)