Healthcare Provider Details

I. General information

NPI: 1205843265
Provider Name (Legal Business Name): MARK HENRY PEDROTTY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CARLISLE BLVD NE STE 224
ALBUQUERQUE NM
87110-1664
US

IV. Provider business mailing address

3029 DELANO PL NE
ALBUQUERQUE NM
87106-2034
US

V. Phone/Fax

Practice location:
  • Phone: 505-688-0601
  • Fax:
Mailing address:
  • Phone: 505-688-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number732
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number732
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number732
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: