Healthcare Provider Details

I. General information

NPI: 1629607890
Provider Name (Legal Business Name): CHARLES DANIEL MARQUEZ PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 MOUNTAIN ROAD PL NE STE R
ALBUQUERQUE NM
87110-7845
US

IV. Provider business mailing address

PO BOX 1134
AZTEC NM
87410-1134
US

V. Phone/Fax

Practice location:
  • Phone: 505-407-5852
  • Fax:
Mailing address:
  • Phone: 505-407-5852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number38070
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: