Healthcare Provider Details

I. General information

NPI: 1023179538
Provider Name (Legal Business Name): JOHN C COURTNEY PSY.D., M.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 HIGHWAY 60
SOCORRO NM
87801-3914
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-2444
  • Fax: 575-838-0150
Mailing address:
  • Phone: 505-982-5565
  • Fax: 505-992-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMPAP000019
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1232
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number0024
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: