Provider Demographics
NPI:1851538771
Name:DETTER, JANINE CHERYL
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:CHERYL
Last Name:DETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 STATE ROAD 502
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-2697
Mailing Address - Country:US
Mailing Address - Phone:505-455-2234
Mailing Address - Fax:
Practice Address - Street 1:1574 STATE ROAD 502
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-2697
Practice Address - Country:US
Practice Address - Phone:505-455-2234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM316925103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool