Healthcare Provider Details

I. General information

NPI: 1982792693
Provider Name (Legal Business Name): JOHN MARK DYKE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7027 MONTGOMERY BLVD NE STE F
ALBUQUERQUE NM
87109-1589
US

IV. Provider business mailing address

7027 MONTGOMERY BLVD NE STE F
ALBUQUERQUE NM
87109-1589
US

V. Phone/Fax

Practice location:
  • Phone: 505-880-0100
  • Fax: 505-880-0102
Mailing address:
  • Phone: 505-880-0100
  • Fax: 505-880-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM-0586
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: