Healthcare Provider Details

I. General information

NPI: 1639271448
Provider Name (Legal Business Name): KEVIN A MAINS LPCC CEDP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 JUAN TABO NE SUITE 16
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

3900 JUAN TABO NE SUITE 16
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-275-6669
  • Fax: 505-298-3939
Mailing address:
  • Phone: 505-275-6669
  • Fax: 505-298-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0069
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: