Healthcare Provider Details

I. General information

NPI: 1073707600
Provider Name (Legal Business Name): VERA D JOHN LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W NIZHONI BLVD SUITE A
GALLUP NM
87301-5766
US

IV. Provider business mailing address

300 W NIZHONI BLVD SUITE A
GALLUP NM
87301-5766
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-9470
  • Fax: 505-722-9570
Mailing address:
  • Phone: 505-722-9470
  • Fax: 505-722-9570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0110991
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: