Healthcare Provider Details

I. General information

NPI: 1134477656
Provider Name (Legal Business Name): JOSEPH CHRISTOPHER WALLOCH PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8800 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-6400
  • Fax: 505-462-6565
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-2023-0019
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: