Healthcare Provider Details

I. General information

NPI: 1073103552
Provider Name (Legal Business Name): ROBERT KEVIN HENNELLY, LPPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 MIGUEL CHAVEZ RD STE F
SANTA FE NM
87505-1111
US

IV. Provider business mailing address

2916 CALLE DERECHA
SANTA FE NM
87505-6530
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-7108
  • Fax:
Mailing address:
  • Phone: 505-629-7108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROBERT K HENNELLY
Title or Position: PSYCHOTHERAPIST
Credential: LPPC
Phone: 505-629-7108