Provider Demographics
NPI:1679945463
Name:JOHN, DEBORAH
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:KOZLOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPAT
Mailing Address - Street 1:2300 W ALAMEDA ST
Mailing Address - Street 2:APT A8
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-9430
Mailing Address - Country:US
Mailing Address - Phone:505-690-3853
Mailing Address - Fax:
Practice Address - Street 1:2300 W ALAMEDA ST
Practice Address - Street 2:APT A8
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-9430
Practice Address - Country:US
Practice Address - Phone:505-690-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0065502101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor