Healthcare Provider Details

I. General information

NPI: 1023431673
Provider Name (Legal Business Name): JOHANNA DEPALMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOHANNA DEPALMA

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 ACADEMY RD NE
ALBUQUERQUE NM
87111-1107
US

IV. Provider business mailing address

8205 SPAIN RD NE SUITE 106
ALBUQUERQUE NM
87109-3179
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-3628
  • Fax: 505-821-3628
Mailing address:
  • Phone: 505-856-0300
  • Fax: 505-856-7946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0166611
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0163671
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: