Provider Demographics
NPI:1588349187
Name:REDHAIR, LATRICIA LYNELLE
Entity type:Individual
Prefix:
First Name:LATRICIA
Middle Name:LYNELLE
Last Name:REDHAIR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL ARTS AVE NE BLDG 3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2722
Mailing Address - Country:US
Mailing Address - Phone:505-860-0433
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE BLDG 3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2722
Practice Address - Country:US
Practice Address - Phone:505-860-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSWB-2023-0436104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker