Provider Demographics
NPI:1215105390
Name:EMBRY, ELDON
Entity type:Individual
Prefix:MR
First Name:ELDON
Middle Name:
Last Name:EMBRY
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 1:921 E. 21ST ST., SUITE D
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4443
Mailing Address - Country:US
Mailing Address - Phone:505-762-0212
Mailing Address - Fax:
Practice Address - Street 1:921 E. 21ST ST., SUITE D
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4443
Practice Address - Country:US
Practice Address - Phone:505-762-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0109931101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor