Healthcare Provider Details

I. General information

NPI: 1932436201
Provider Name (Legal Business Name): MATTHEW JEAN DUTTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2009
Last Update Date: 11/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 TIJERAS AVE NW
ALBUQUERQUE NM
87102-3096
US

IV. Provider business mailing address

803 TIJERAS AVE NW
ALBUQUERQUE NM
87102-3096
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-2223
  • Fax: 505-243-3576
Mailing address:
  • Phone: 505-243-2223
  • Fax: 505-243-3576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberT-0124951
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: