Provider Demographics
NPI:1548517790
Name:PACHECO, ERICK BRIAN (LADAC)
Entity type:Individual
Prefix:MR
First Name:ERICK
Middle Name:BRIAN
Last Name:PACHECO
Suffix:
Gender:M
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 ASBURY RD NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-5627
Mailing Address - Country:US
Mailing Address - Phone:505-489-4935
Mailing Address - Fax:
Practice Address - Street 1:1207 GOLF COURSE RD SE
Practice Address - Street 2:SUITE C
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1999
Practice Address - Country:US
Practice Address - Phone:505-994-4100
Practice Address - Fax:505-994-1229
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0164561101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93588755Medicaid