Provider Demographics
NPI:1811499908
Name:ARCHULETA, THOMAS RAMON (LSAA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAMON
Last Name:ARCHULETA
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
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Mailing Address - Street 1:6452 HOOCHANEETSA BLVD
Mailing Address - Street 2:
Mailing Address - City:COCHITI LAKE
Mailing Address - State:NM
Mailing Address - Zip Code:87083-6029
Mailing Address - Country:US
Mailing Address - Phone:505-577-5974
Mailing Address - Fax:
Practice Address - Street 1:1264 RODEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6816
Practice Address - Country:US
Practice Address - Phone:505-982-2129
Practice Address - Fax:505-992-1149
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0180621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)