Healthcare Provider Details

I. General information

NPI: 1518277235
Provider Name (Legal Business Name): JOHN DAVID COYLE LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E ROOSEVELT AVE
GRANTS NM
87020-2220
US

IV. Provider business mailing address

700 E ROOSEVELT AVE
GRANTS NM
87020-2220
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-2273
  • Fax: 505-287-2276
Mailing address:
  • Phone: 505-287-2273
  • Fax: 505-287-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3026
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: