MEDICARE: DR OSVELIA G DEEDS LLC

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	103T00000X	Psychologist	1095	NM

General Provider Information

NPI Number	:	1912275124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR OSVELIA G DEEDS LLC

Provider Business Mailing Address
First Line	:	1542 ROSALBA ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-6552
Country	:	US
Telephone Number	:	505-850-5314
Fax Number	:

Provider Business Practice Location Address
First Line	:	5203 JUAN TABO BLVD NE STE 2B
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-2691
Country	:	US
Telephone Number	:	505-850-5314
Fax Number	:	505-221-5710

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	DAWN HALFACRE
Credential	:
Telephone Number	:	505-352-5269

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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Directions to “DR OSVELIA G DEEDS LLC ” Practice Location

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