Provider Demographics
NPI:1720690092
Name:SCHWARTZ, KENNETH JUSTIN
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JUSTIN
Last Name:SCHWARTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 MARGARITA DR SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2699
Mailing Address - Country:US
Mailing Address - Phone:505-803-8791
Mailing Address - Fax:
Practice Address - Street 1:2319 MARGARITA DR SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2699
Practice Address - Country:US
Practice Address - Phone:505-803-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-18
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician