Healthcare Provider Details

I. General information

NPI: 1407979990
Provider Name (Legal Business Name): LAWRENCE ELDEN DETTWEILER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 CERRILLOS RD
SANTA FE NM
87501-3784
US

IV. Provider business mailing address

14 MELADO DR
SANTA FE NM
87508-2254
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-0641
  • Fax:
Mailing address:
  • Phone: 505-603-0641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4706
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: