Healthcare Provider Details

I. General information

NPI: 1023172806
Provider Name (Legal Business Name): JOHN DOUGLAS HUMPHREYS LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 LOMAS BLVD NE STE. #116
ALBUQUERQUE NM
87112-5401
US

IV. Provider business mailing address

PO BOX 13146
ALBUQUERQUE NM
87192-3146
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-7421
  • Fax: 505-275-3859
Mailing address:
  • Phone: 505-459-7421
  • Fax: 505-275-3859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1223
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: