Healthcare Provider Details

I. General information

NPI: 1285232397
Provider Name (Legal Business Name): DR TONY J KREUCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 BROTHERS RD STE B
SANTA FE NM
87505-6975
US

IV. Provider business mailing address

3201 ZAFARANO DR STE C
SANTA FE NM
87507-2672
US

V. Phone/Fax

Practice location:
  • Phone: 505-269-9015
  • Fax:
Mailing address:
  • Phone: 505-269-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TONY KREUCH
Title or Position: CEO
Credential: PSYD
Phone: 505-269-9015