Healthcare Provider Details

I. General information

NPI: 1477611341
Provider Name (Legal Business Name): BARBARA KOLTUSKA, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11927 MENAUL BLVD NE STE 107
ALBUQUERQUE NM
87112-2457
US

IV. Provider business mailing address

11927 MENAUL BLVD NE STE 107
ALBUQUERQUE NM
87112-2457
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-5003
  • Fax: 505-292-5003
Mailing address:
  • Phone: 505-292-5003
  • Fax: 505-292-5003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number580
License Number StateNM

VIII. Authorized Official

Name: DR. BARBARA KOLTUSKA-HASKIN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 505-292-5003