Provider Demographics
NPI:1528289287
Name:AUTRY, JOE BOB (PHD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:BOB
Last Name:AUTRY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105303 ROAD 66
Mailing Address - Street 2:
Mailing Address - City:KIM
Mailing Address - State:CO
Mailing Address - Zip Code:81049
Mailing Address - Country:US
Mailing Address - Phone:719-643-5323
Mailing Address - Fax:
Practice Address - Street 1:101 SECOND NORTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740
Practice Address - Country:US
Practice Address - Phone:505-445-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM271964103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool