Healthcare Provider Details

I. General information

NPI: 1548877855
Provider Name (Legal Business Name): GERASIMOS DEMOSTHENIS KLONIS LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 01/14/2024
Certification Date: 01/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 6TH ST S
SOCORRO NM
87801-4139
US

IV. Provider business mailing address

3056 FRONTIER AVE NE
ALBUQUERQUE NM
87106-2037
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4140
  • Fax:
Mailing address:
  • Phone: 505-865-4140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCTB-2023-0800
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: