Healthcare Provider Details

I. General information

NPI: 1023315017
Provider Name (Legal Business Name): SOUTHWEST NEUROPSYCHOLOGY AND BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 GOLD AVE SW SUITE 1001
ALBUQUERQUE NM
87102-3202
US

IV. Provider business mailing address

320 GOLD AVE SW SUITE 1001
ALBUQUERQUE NM
87102-3202
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4900
  • Fax:
Mailing address:
  • Phone: 505-247-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1148
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1148
License Number StateNM

VIII. Authorized Official

Name: DR. JONATHAN RYAN KURTYKA
Title or Position: ORGANIZER
Credential: PH.D.
Phone: 505-247-4900