Healthcare Provider Details

I. General information

NPI: 1861606246
Provider Name (Legal Business Name): TOMAS R. GRANADOS, PSY.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4313
US

IV. Provider business mailing address

PO BOX 93874
ALBUQUERQUE NM
87199-3874
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-0810
  • Fax: 505-797-0814
Mailing address:
  • Phone: 505-797-0810
  • Fax: 505-797-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number702
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number702
License Number StateNM

VIII. Authorized Official

Name: DR. TOMAS REFUGIO GRANADOS
Title or Position: OWNER
Credential: PSY.D.
Phone: 505-797-0810