Provider Demographics
NPI:1528359916
Name:JOE, KENNETH A (DINE' TRADITIONAL)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:JOE
Suffix:
Gender:M
Credentials:DINE' TRADITIONAL
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 1144
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-1144
Mailing Address - Country:US
Mailing Address - Phone:505-786-2111
Mailing Address - Fax:505-786-5442
Practice Address - Street 1:SOUTHWEST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313-1144
Practice Address - Country:US
Practice Address - Phone:505-786-2111
Practice Address - Fax:505-786-5442
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDHA 052OtherDINE' HATAALII
NMDHA 052OtherDINE' TRADITIONAL COUNSELOR