Basic Information
| Provider Information | |||||||||
| NPI: | 1518106814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAABE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | WALLACE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | LADAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3821 W COLLEGE LN | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882429126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753922231 | ||||||||
| FaxNumber: | 5753926484 | ||||||||
| Practice Location | |||||||||
| Address1: | 3821 W COLLEGE LN | ||||||||
| Address2: | |||||||||
| City: | HOBBS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882429126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5753922231 | ||||||||
| FaxNumber: | 5753926484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0103031 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 800521083 | 01 | NM | MEDICARE GROUP NUMBER | OTHER | 000463000 | 05 | NM | MEDICAID |