Provider Demographics
NPI:1255598108
Name:SANCHEZ, KENNY D (L A D A C)
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:D
Last Name:SANCHEZ
Suffix:
Gender:M
Credentials:L A D A C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 VANDEN BOSCH PKWY
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5508
Mailing Address - Country:US
Mailing Address - Phone:505-726-6931
Mailing Address - Fax:505-722-5862
Practice Address - Street 1:650 VANDEN BOSCH PKWY
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5508
Practice Address - Country:US
Practice Address - Phone:505-726-6931
Practice Address - Fax:505-722-5862
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0066982101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)