Provider Demographics
NPI:1548353931
Name:COHEN, M. (PHD)
Entity type:Individual
Prefix:DR
First Name:M.
Middle Name:
Last Name:COHEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CIELO DE ORO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508
Mailing Address - Country:US
Mailing Address - Phone:505-986-6133
Mailing Address - Fax:866-431-2050
Practice Address - Street 1:532 DON GASPAR AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-986-6133
Practice Address - Fax:866-431-2050
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2122-0057103TC0700X
NM0980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39125800Medicaid