Healthcare Provider Details

I. General information

NPI: 1144332925
Provider Name (Legal Business Name): SAMUEL ROLL PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 05/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TULANE DR SE
ALBUQUERQUE NM
87106-1413
US

IV. Provider business mailing address

1616 SAN PATRICIO AVE SW
ALBUQUERQUE NM
87104-1048
US

V. Phone/Fax

Practice location:
  • Phone: 505-255-9494
  • Fax: 505-242-4763
Mailing address:
  • Phone: 505-255-9494
  • Fax: 505-242-4763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number105
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: