Provider Demographics
NPI:1306949516
Name:DRAPER, JOHN (PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DRAPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:M
Other - Last Name:DRAPER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1978
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1978
Mailing Address - Country:US
Mailing Address - Phone:505-623-1480
Mailing Address - Fax:505-622-3325
Practice Address - Street 1:110 E MESCALERO RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6542
Practice Address - Country:US
Practice Address - Phone:505-623-1480
Practice Address - Fax:505-622-3325
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM721103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT7878Medicaid