Healthcare Provider Details

I. General information

NPI: 1104636158
Provider Name (Legal Business Name): SANDIA HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4313
US

IV. Provider business mailing address

524 CENTRAL AVE SW UNIT 401
ALBUQUERQUE NM
87102-3139
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-9478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: REZA HEALTHCARE GROUP EHSANIAN
Title or Position: OWNER
Credential: MD
Phone: 408-687-8206