Provider Demographics
NPI:1407979990
Name:DETTWEILER, LAWRENCE ELDEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:ELDEN
Last Name:DETTWEILER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MELADO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-2254
Mailing Address - Country:US
Mailing Address - Phone:505-603-0641
Mailing Address - Fax:
Practice Address - Street 1:453 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-3784
Practice Address - Country:US
Practice Address - Phone:505-603-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12452777Medicaid
NMVNM01398OtherVALUE OPTIONS