Healthcare Provider Details

I. General information

NPI: 1619349479
Provider Name (Legal Business Name): JOHN LYKINS LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BROADWAY BLVD NE SUITE 103
ALBUQUERQUE NM
87102-2360
US

IV. Provider business mailing address

11024 MONTGOMERY BLVD NE PMB 360
ALBUQUERQUE NM
87111-3962
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-4639
  • Fax: 505-206-5680
Mailing address:
  • Phone: 505-738-3928
  • Fax: 505-738-3922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0176641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: