Healthcare Provider Details

I. General information

NPI: 1881033231
Provider Name (Legal Business Name): CLINICAL, FORENSIC NERUOPSYCHOLOGIST ASSOCIATES OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3228 LOS ARBOLES AVE NE BLDG. 1-230
ALBUQUERQUE NM
87107-1962
US

IV. Provider business mailing address

3228 LOS ARBOLES AVE NE BLDG. 1-230
ALBUQUERQUE NM
87107-1962
US

V. Phone/Fax

Practice location:
  • Phone: 505-331-2829
  • Fax: 505-821-3365
Mailing address:
  • Phone: 505-331-2829
  • Fax: 505-821-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1130
License Number StateNM

VIII. Authorized Official

Name: DR. SHARON KERNEN
Title or Position: DEPARTMENT OF HEALTH PROVIDER
Credential: PH.D.
Phone: 505-263-8055