Healthcare Provider Details

I. General information

NPI: 1932200417
Provider Name (Legal Business Name): KENNETH KRISS GOODROW II MS, LPCC, NCC, CCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3949 CORRALES RD STE 105
CORRALES NM
87048-9347
US

IV. Provider business mailing address

4101 CORRALES RD UNIT 520
CORRALES NM
87048-4020
US

V. Phone/Fax

Practice location:
  • Phone: 505-239-7459
  • Fax: 505-899-4060
Mailing address:
  • Phone: 505-239-7459
  • Fax: 505-899-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0078151
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: