Healthcare Provider Details

I. General information

NPI: 1679080600
Provider Name (Legal Business Name): KERMIT ANDREW COLE MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 FUEGO SAGRADO
SANTA FE NM
87505-5114
US

IV. Provider business mailing address

2930 FUEGO SAGRADO
SANTA FE NM
87505-5114
US

V. Phone/Fax

Practice location:
  • Phone: 917-751-4366
  • Fax: 917-751-4366
Mailing address:
  • Phone: 917-751-4366
  • Fax: 917-751-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCMF0199641
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: