Healthcare Provider Details

I. General information

NPI: 1639240781
Provider Name (Legal Business Name): JOHN DEXTER KOHN LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 CALLE DE LEON
SANTA FE NM
87505-7303
US

IV. Provider business mailing address

615 CALLE DE LEON
SANTA FE NM
87505-7303
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8735
  • Fax: 505-982-0264
Mailing address:
  • Phone: 505-982-8735
  • Fax: 505-982-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2113
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: