Healthcare Provider Details

I. General information

NPI: 1871246819
Provider Name (Legal Business Name): LELAND GUTHRIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST STE O
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

12B ECKARDS WAY
ESPANOLA NM
87532-9878
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-9169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY1711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: