Basic Information
| Provider Information | |||||||||
| NPI: | 1396065488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSE | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N. INDIANA AVE. | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860471269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9282896225 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N. INDIANA AVENUE | ||||||||
| Address2: | |||||||||
| City: | WINSLOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860471269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282894646 | ||||||||
| FaxNumber: | 9282896225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 06/11/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0132471 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0132471 | 01 | NM | LADAC | OTHER |