Healthcare Provider Details

I. General information

NPI: 1215773254
Provider Name (Legal Business Name): ROBERT E DEACON MA, LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4308 CARLISLE BLVD NE STE 210
ALBUQUERQUE NM
87107-4849
US

IV. Provider business mailing address

4308 CARLISLE BLVD NE STE 210
ALBUQUERQUE NM
87107-4849
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-1921
  • Fax: 505-247-1020
Mailing address:
  • Phone: 505-247-1921
  • Fax: 505-247-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2024-0389
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: