Healthcare Provider Details

I. General information

NPI: 1851538771
Provider Name (Legal Business Name): JANINE CHERYL DETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1574 STATE ROAD 502
SANTA FE NM
87506-2697
US

IV. Provider business mailing address

1574 STATE ROAD 502
SANTA FE NM
87506-2697
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-2234
  • Fax:
Mailing address:
  • Phone: 505-455-2234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number316925
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: