Healthcare Provider Details

I. General information

NPI: 1639328628
Provider Name (Legal Business Name): DAVID KERR ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 PRIESTLY PL
CORRALES NM
87048-9323
US

IV. Provider business mailing address

39 PRIESTLY PL
CORRALES NM
87048-9323
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-6278
  • Fax:
Mailing address:
  • Phone: 505-899-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0089111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: