Healthcare Provider Details

I. General information

NPI: 1124584313
Provider Name (Legal Business Name): MARK SIMPSON PSYD MAC LADC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 CARLISLE BLVD NE STE G
ALBUQUERQUE NM
87110-2867
US

IV. Provider business mailing address

2920 CARLISLE BLVD NE STE G
ALBUQUERQUE NM
87110-2867
US

V. Phone/Fax

Practice location:
  • Phone: 505-977-9180
  • Fax: 505-792-7982
Mailing address:
  • Phone: 505-977-9180
  • Fax: 505-792-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARK STEWART SIMPSON
Title or Position: OWNER
Credential: PSYD LADC LPCC
Phone: 505-977-9180