Healthcare Provider Details

I. General information

NPI: 1194013490
Provider Name (Legal Business Name): MR. KENNETH BART DODSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 N COCHITI AVE
FARMINGTON NM
87401-4237
US

IV. Provider business mailing address

PO BOX 322
FARMINGTON NM
87499-0322
US

V. Phone/Fax

Practice location:
  • Phone: 505-613-6909
  • Fax:
Mailing address:
  • Phone: 505-613-6909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0139981
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC09762
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: