Provider Demographics
NPI:1124108055
Name:FRADY, BOBBI JEAN (MC,LADAC)
Entity type:Individual
Prefix:
First Name:BOBBI
Middle Name:JEAN
Last Name:FRADY
Suffix:
Gender:F
Credentials:MC,LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:750 MORRIS RD SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-5242
Practice Address - Country:US
Practice Address - Phone:505-866-2318
Practice Address - Fax:505-869-4881
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3699101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3699OtherLICENSE