Provider Demographics
NPI:1518704485
Name:EHSAN, BAKHTAR
Entity type:Individual
Prefix:
First Name:BAKHTAR
Middle Name:
Last Name:EHSAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 SAN PEDRO DR NE STE 14
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3399
Mailing Address - Country:US
Mailing Address - Phone:831-325-3541
Mailing Address - Fax:
Practice Address - Street 1:1201 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1403
Practice Address - Country:US
Practice Address - Phone:831-325-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker