Basic Information
| Provider Information | |||||||||
| NPI: | 1073049557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOWAN | ||||||||
| FirstName: | DUSTIN | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N PASEO DE ONATE | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322687 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2960 RODEO PARK DR W | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875056351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059869633 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CMH0188251 | NM | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 0188251 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.