Healthcare Provider Details

I. General information

NPI: 1104156058
Provider Name (Legal Business Name): JONATHAN KURTYKA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 GOLD AVE SW SUITE 1001
ALBUQUERQUE NM
87102-3228
US

IV. Provider business mailing address

320 GOLD AVE SW SUITE 1001
ALBUQUERQUE NM
87102-3228
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4900
  • Fax:
Mailing address:
  • Phone: 505-247-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: