Provider Demographics
NPI:1801303276
Name:DAHL-BREDINE, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DAHL-BREDINE
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 1:2329 COTTAGE SAN RD
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-8988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1311 N GRANT ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5134
Practice Address - Country:US
Practice Address - Phone:575-519-9232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-06
Last Update Date:2018-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10217104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker