Healthcare Provider Details

I. General information

NPI: 1962532648
Provider Name (Legal Business Name): BOBBY N. HOLSTEAD, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9426 INDIAN SCHOOL RD NE SUITE 1
ALBUQUERQUE NM
87112-2887
US

IV. Provider business mailing address

855 FAIRWAY RD NW
ALBUQUERQUE NM
87107-5720
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-9500
  • Fax: 866-808-7651
Mailing address:
  • Phone: 505-344-9500
  • Fax: 866-808-7651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number214
License Number StateNM

VIII. Authorized Official

Name: BOBBY N. HOLSTEAD
Title or Position: OWNER
Credential: PH.D.
Phone: 505-344-9500