Basic Information
| Provider Information | |||||||||
| NPI: | 1861738924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDDY | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | IRENE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 COORS BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871201213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053383320 | ||||||||
| FaxNumber: | 5052883636 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 MORRIS RD SE | ||||||||
| Address2: | |||||||||
| City: | LOS LUNAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870315242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058662318 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2012 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | M-08187 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 44842 | 05 | NM | MEDICAID |