Provider Demographics
NPI:1659181808
Name:KOTTLE, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:KOTTLE
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 1:3952 SAN FELIPE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-8073
Mailing Address - Country:US
Mailing Address - Phone:505-471-8575
Mailing Address - Fax:
Practice Address - Street 1:3952 SAN FELIPE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-8073
Practice Address - Country:US
Practice Address - Phone:505-471-8575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health