Healthcare Provider Details

I. General information

NPI: 1386081933
Provider Name (Legal Business Name): KATHRYN DZIEKAN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

IV. Provider business mailing address

612 N PASEO DE ONATE
ESPANOLA NM
87532-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-2203
  • Fax: 505-747-1881
Mailing address:
  • Phone: 505-753-2203
  • Fax: 505-747-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0114971
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: