MEDICARE: SUMMER ROLIN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	1409	NM
2	103TC0700X	Clinical Psychologist	1409	NM

General Provider Information

NPI Number	:	1730534587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMMER ROLIN PSY.D.

Provider Business Mailing Address
First Line	:	10101 DENALI CT NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111
Country	:	US
Telephone Number	:	832-594-2787
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 INDIAN SCHOOL RD NE STE 310
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-3832
Country	:	US
Telephone Number	:	832-594-2787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2016
Last Update Date	:	04/29/2016

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