Healthcare Provider Details

I. General information

NPI: 1902091531
Provider Name (Legal Business Name): DARREL RICHARD KNUTSON LMHC MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1103
US

IV. Provider business mailing address

PO BOX 16778
ALBUQUERQUE NM
87191-6778
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-1820
  • Fax: 505-881-1850
Mailing address:
  • Phone: 505-489-1283
  • Fax: 505-292-4116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0107091
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: