Healthcare Provider Details

I. General information

NPI: 1851004188
Provider Name (Legal Business Name): MR. P JON DEPALMA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 GENERAL CHENNAULT ST NE
ALBUQUERQUE NM
87123-2515
US

IV. Provider business mailing address

35 SIERRA VISTA DR
CEDAR CREST NM
87008-9459
US

V. Phone/Fax

Practice location:
  • Phone: 383-350-5900
  • Fax:
Mailing address:
  • Phone: 719-332-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: