Healthcare Provider Details

I. General information

NPI: 1265178164
Provider Name (Legal Business Name): ANDREW JAMES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 491 PINON/COTTOWOOD DR BLG. 2301
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 1830
SHIPROCK NM
87420
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-1438
  • Fax: 505-368-1437
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberBHA172
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: