Provider Demographics
NPI:1306046487
Name:CALABAZA, LUCIANO (LADAC)
Entity type:Individual
Prefix:MR
First Name:LUCIANO
Middle Name:
Last Name:CALABAZA
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TESUQUE ST
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-9998
Mailing Address - Country:US
Mailing Address - Phone:505-465-2733
Mailing Address - Fax:505-465-0433
Practice Address - Street 1:10 TESUQUE ST
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052-9998
Practice Address - Country:US
Practice Address - Phone:505-465-2733
Practice Address - Fax:505-465-0433
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3697101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)