Healthcare Provider Details

I. General information

NPI: 1508912650
Provider Name (Legal Business Name): ROBERT WINTHROP DEANE LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2871 CLARK CT
SANTA FE NM
87507-5179
US

IV. Provider business mailing address

2442 CERRILLOS RD PMB 268
SANTA FE NM
87505-3262
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-3202
  • Fax:
Mailing address:
  • Phone: 505-670-3202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0077991
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: