Healthcare Provider Details

I. General information

NPI: 1497114003
Provider Name (Legal Business Name): PRISMTHERAPEUTIC SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GUN CLUB RD SW
ALBUQUERQUE NM
87105-6415
US

IV. Provider business mailing address

2200 GUN CLUB RD SW
ALBUQUERQUE NM
87105-6415
US

V. Phone/Fax

Practice location:
  • Phone: 505-681-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number4368
License Number StateNM

VIII. Authorized Official

Name: ANDREA MONTOYA
Title or Position: OWNER
Credential: MS, CCC, SLP/ BCBA
Phone: 505-681-7000