Provider Demographics
NPI:1023179538
Name:COURTNEY, JOHN C (PSYD, MP)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:COURTNEY
Suffix:
Gender:M
Credentials:PSYD, MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:505-982-5565
Mailing Address - Fax:505-992-4990
Practice Address - Street 1:1200 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-835-2444
Practice Address - Fax:575-838-0150
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMPAP000019103TP0016X
NM1232103G00000X
NM0024103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17472717Medicaid
LA1004812Medicaid
IN169350Medicare PIN