Healthcare Provider Details

I. General information

NPI: 1669646659
Provider Name (Legal Business Name): ERIC MASON WESTFRIED PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 GOLD AVE SW SUITE #202
ALBUQUERQUE NM
87102-3300
US

IV. Provider business mailing address

215 GOLD AVE SW SUITE #202
ALBUQUERQUE NM
87102-3300
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4401
  • Fax: 505-243-2776
Mailing address:
  • Phone: 505-242-4401
  • Fax: 505-243-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number641
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1943
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: